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Friday Apr 05, 2019

Objection! Can We Bring Order to Documentation and Billing?

Dear Lawyers,

You got it right. Your operations make sense. I know this is wrong for me to say -- doctors and lawyers are often at odds with one another -- but I have to tip my cap here. I have this unsettling feeling that -- from a professional standpoint -- your billing practices make sense. And the way you do your documentation also makes sense. Your delegation and hierarchy make sense. You've evolved a system whereby you run things in a way that lets you focus on practicing law.

[what is billable envelope]

We still haven't figured that out in medicine.

Let me put it this way: Many primary care physicians look at their calendars for the day and see 20 to 25 (or maybe more!) 20-minute meetings (appointments) scheduled. Each of these meetings has no concrete agenda, and the physician is expected to attend on time, discuss whatever concern comes up, research and/or make a plan to address that concern, cross any t's or dot any i's necessary for executing that plan, then create the legal written record of the interaction.

That's the process. Dozens of times over. Every day.

And if a physician is unable to perform all those tasks during the 20 minutes scheduled for a meeting, one of the following will occur:

  • They won't ever get done, and one of those elements falls through the cracks.
  • They get done at the end of the workday -- or maybe at the end of the workweek -- during the physician's personal time.

This is insanity.

Now, I'm not a lawyer, so I may be off on some points here (cue online trolling …), but it seems as though the legal profession has figured out how to serve its clients without creating the kind of chaos that medicine has created.

First, legal meetings generally have agendas -- or at least expectations -- set before they occur. A lawyer (and potentially the client) has prepared to execute on ideas, tasks or discussion prior to the visit. This may be because communication is easier with your lawyer than with your physician.

Second, legal meetings are generally scheduled for longer than 20 minutes, and if work needs to occur outside of that 20-minute slot to aid the client, that work is done. And it's billed. The client -- whether they like it or not -- is expected to pay for the lawyer's time. Time is the most finite resource, and it needs to be protected and valued as much by clients as by the provider of a service.

I can't say how much any given doctor is worth on an hourly basis; that's not the point of today's discussion. The point is that lawyers expect to do as much work as is needed and they set an equal expectation to be compensated for how long that work takes. This isn't isolated to lawyers, either. Think: graphic designers, computer developers, contract workers, accountants, plumbers, etc.

(As an aside: This practice drives me a little nuts as a client. I was once billed $48 for a fax that was sent by a lawyer I eventually fired. But that's another conversation.)

Lastly, when legal documentation must occur, it happens in real time with stenographers. Lawyers aren't in a courtroom trying to argue their case while feverishly documenting what is being said and discussed. That would be insane.

Can medicine make improvements in these three areas?

  • Can we get better about setting agendas and doing prework for our visits? Can patients easily tell us their concerns? And would them describing their concerns in advance ultimately lead to a decrease in the need for visits? What if we could address their concerns without an in-person visit? And if visits need to occur, having a clear agenda and expectations may help both the provider and the patient get what they want from their time together. Moreover, as algorithms, artificial intelligence, machine learning, deep learning, etc., become more and more useful, allowing time for use of these technologies (both before and during the visit), they will become more and more important. I believe much of this hurdle revolves around the fact that doctors have little control over the manner in which they set up their practices and in which they bill and are paid for their services.
  • What if we were paid for our time as physicians? There is an often-cited study(annals.org) that notes that for every hour a physician spends in front of his or her patient, he or she needs an additional two hours of time in front of the computer. In a real sense, the 20-minute visit must be thought of as 20 minutes with a patient and 40 minutes of coordination of care, billing, documentation and everything else that's expected.
  • We need documentation, no question. But are we doing it right? What once was scribbles on paper has morphed into a magnetic attraction of the physician to the computer. Some systems are moving toward more scribes, others to an experience where one clinic staffer sticks with a patient through the entire visit. Regardless, we need the equivalent of stenographers -- whether they're robots or people -- if we physicians are going to work at the top of our ability. Physicians train for more than a decade to think critically about a person's care; it's absurdly expensive to use us as claims processors or data enterers.

So, for you lawyers out there, as much as it kills me, I think you've got something figured out. We've just got to figure out a way to incorporate it into what we physicians do. Otherwise, we're burning ourselves out of our profession. Any advice appreciated. (But please don't bill me for it.)

Allison Edwards, M.D.

Allison Edwards, M.D., founded and cares for patients at Kansas City Direct Primary Care;(www.kansascitydirectprimarycare.com) provides locums coverage at rural hospitals with Docs Who Care in Missouri, Kansas and Colorado; and is volunteer faculty at both the University of Colorado and the University of Kansas. You can follow her on Twitter @KansasCityDPC.(twitter.com)

Read other posts by this blogger.  

Posted at 04:21PM Apr 05, 2019 by Allison Edwards, M.D.

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