The “necessity-burden monster” are words of my own choosing, and does not reflect any authoritatively-stated or generally-accepted health care paradigm. It is, for me, an apt summation for how the progressive stages of the administrative side of health care have become a degeneration to the original intention of keeping medical records: to assist in patient care.
What it has undergone, particularly in the last twenty years or so, and when compared to the prognostications of what this technology and regulation was supposed to have achieved by now, shows for me a severe downward progression — a move from the institution of a few simple administrative necessities, to the growth of unnecessarily burdensome administrative requirements, and finally to the present day administrative practices that have ballooned to monstrous, unsustainable proportions.
Of course, no one has ever argued against the necessity for improvement in the accuracy and completion of health record documentation of an episode of patient care. Keeping an accurate record was established as a clinical necessity long before being considered a necessity for administrative purposes — standards for clinical documentation were developed by physicians of the American College of Surgeons (ACS) almost a century ago. The elements of documentation that make up the modern-day comprehensive medical record were formulated by the physicians in the ACS (the history and physical report, the discharge summary, the daily dictated or scanned physician and non-physician progress notes, and so forth), and to further cement consistency, these physicians developed a standard framework for the presentation of information in their reports and notes: the subjective, objective, assessment, plan (or SOAP) format. As one of my former college teachers, who is also an RN and a CDI trainer, has jokingly remarked, “SOAP is what has been keeping us clean and smelling good.”
These standards, of course, were clinically-guided standards, or overall standards for the practice of health care itself, and not for guiding any certain administrative processes, as that entire component started growing within the practice of health care only over the last half-century. Furthermore, the newer documentation necessities that sprang up in the late 1970s and then further into the 80s and 90s regarding the medical record were almost solely concerning this growing administrative component.
Administrative necessity
The computerization of clinical information systems and of data capturing during patient registration procedures, throughout the 1960s and 1970s, became the basis into the early 1980s for the first generation of separately-developed information systems to serve administrative purposes. By the mid- to late-1980s, certain administrative processes were to become institutionalized necessities in health care – the prior decades of the fee-for-service reimbursement scheme changed irrevocably when Medicare instituted the Prospective Payment System (PPS) in 1985. Because of this change, pretty much every other insurance player in the industry followed suit and adopted this reimbursement practice.
Along with the initiation of ICD-9-CM in 1979 and CPT-4 in 1987, the PPS scheme prompted the development of a second generation of information systems comprised of financial and administrative systems wrapped together, retooling the entire function of medical records management. The assignment of units of cost and reimbursement for health care services would now develop, from the late-1980s into the mid-1990s, into procedures for identifying and manipulating revenue streams and cost streams.
Administrative burden
Such procedures would eventually multiply, concatenate and be bundled together to form the “health care revenue cycle,” an entire lego-like construct of invisible artifice now present in every hospital and physician’s office, its digital tentacles continually reaching into health care operations through daily spreadsheets and customized administrative reports.
Parallel to this growth of medical billing into its own economic cycle was the growth of networking capabilities for data inputted or captured into computerized medical records. This would prompt an industry shift from unstructured to structured forms of health care documentation, and this did produce some very beneficial approaches as practitioners transitioned from the written narrative to documentation with data sets. Probably the most innovative approach that I’ve read about was designed by physicians themselves: the emergency department “T Sheet,” developed by Woodrow Gandy, MD, and Rob Langdon, MD in 1994.
The late-1990s saw the rise of electronic health record (EHR) software, the third and latest generation of information systems to govern medical records management The brevity of information in the paper medical record or in the simple computerized form becomes supplanted by the massive serialization and piecemealing of information in the modern computer record system. Starting into the new millennium, administrative necessities become larger and more complicated bodies of policy and procedure that inevitably shift into being burdens for health care practitioners.
Administrative monstrosity
The end of the first decade of this millennium saw the rise of legislation to increase use and ownership of these computer record systems by health care practitioners. I began coding just two years before the HITECH Act of 2009, and in the last eight years, I’ve used many of the common EHR systems available in the market. My study in this field can only lead me to concur with what physicians and other health care practitioners have repeatedly commented on this website, and in other mediums: the rise of health care administration has crossed into a madly dysfunctional sphere, a monstrosity.
The degree of fragmentation is unprecedented – whereas twenty or thirty years ago, a physician or nurse would make rounds with a compact set of papers in a medical file, undertaking patient care while trying to fulfill every mandated requirement of an electronic medical record seems to me analogous to doctors or nurses lugging around big, plastic storage bins on their backs, full of different files and looseleaf papers, with which they have to frantically rummage through for the information they need every time they walk into a different patient’s room.
The level of robotization expected is also unprecedented, and unacceptable, to health care practitioners. Just as you would not expect people to purchase tickets to a rock concert where the performance stage was empty except for a table and a computer that “generated” music, you would similarly not expect patients to accept the evaluation and treatment of their illnesses delivered through the prim, uninterruptible monologue of a white-coated C-3PO. And yet, administrative forces press and squeeze clinical practitioners every day towards outcomes that are as analogously unsustainable.
I read a statistic in a market analysis report done in 2006 by an independent merchant bank called TripleTree. The report stated, “A recent study by Harvard Medical School and Public Citizen estimated that 31 percent of the $1.3 trillion in U.S. outlays for health care in 2003 was devoted to administrative paperwork.”
As we now finish up 2015, I wonder just how much higher this figure has become.
Rene Datta is a medical coder.
