The insanely wasteful American health care system spends a ton of money on a multitiered system. A large percentage of the population is either underinsured or uninsured, while patients in the higher tiers suffer from a surplus of specialists. All too frequently, these poor souls end up with a different specialist for every organ of the body, leading to fragmented care that is very expensive.
Our political leadership struggled ineffectively for decades to understand the root causes of this sorry situation, until someone in Washington finally realized that the key to fixing the health care debacle is primary care. Well, duh!
This brainstorm in the nation’s capital led to a recent explosion of paperwork in my office, and that caught my attention. I was wondering which genius I should thank for this, and lo and behold, it’s the federal government. After doing some cursory online research (that means I cursed and muttered under my breath while I googled my way to the answers I needed) I discovered that the American Recovery and Reinvestment Act of 2009 (ARRA) authorizes Medicare to give extra money to "eligible providers" who become "meaningful users" of electronic health records (EHRs). Instantly, the term "meaningful use" rubbed me the wrong way. The term implies that whatever we were doing before this legislative masterpiece wasn’t meaningful, and might not be the ticket to get on the Medicare gravy train.
My office started trying to establish our bona fides as meaningful users in 2011 with e-prescribing, which is another aspect of meaningful use.
The year 2012 brought about a comically exaggerated resurgence of the new patient health questionnaire. This detailed document requires patients to fill out their social history, allergies, medication list, past hospital admissions, surgeries, family history, and a long review of systems. Before we had to document our high quality as physicians, we used to give this very detailed three-page questionnaire to each new patient, but the federal government, in its infinite wisdom, decided the old way of history taking wasn’t meaningful enough. To show our dedication to meaningful history taking, and the extra reimbursement it entails, we expanded our questionnaire into a bloated four-page document, and each year we make patients fill out a new one. These days, most of my patients have clipboards thick with forms.
In addition to the four-page health questionnaire, my office also gives patients another two-page form to update their insurance and contact information, and patients with rheumatoid arthritis fill out the two-page MD-HAQ (Multidisciplinary Health Assessment Questionnaire). That’s eight pages just to see me for an office follow-up visit scheduled for 15 minutes.
Passing out piles of paper to patients is a relatively easy task for the staff, but practically all my patients have been grumbling about all the forms, and many patients have been unwilling or unable to comply with this new documentation burden. Were I to tell my patients, as they slave over their clipboards, that "this extra paperwork makes me a meaningful user, and allows me to eke out a few more dollars from Medicare," I doubt that my patients would consider this a meaningful use of their time. Keeping patient records up to date is great, but there has to be a better way of doing it.
When I see a patient whom I haven’t seen in a long time, I frequently ask, "Have you had any surgery since last I saw you?" It isn’t necessary for patients to reiterate their entire surgical history. If a patient tells me, "I had my knee replaced recently," that’s important information. If the patient describes their appendectomy in 1932, that certainly has nostalgic value, but is irrelevant to the issues at hand. At least one patient complained "I’m in my 70s and I can’t remember all of this." Many times, family members help the patient wade through all the questions. This sometimes creates interesting synergies. I entered an exam room and found a daughter reading the questions out loud to help her mother. "Mom, have you ever had breast implants?"
The most important part of the four-page health questionnaire is the signature line on the last page. If I fail to sign my name, I will be visited later in the afternoon by the signature clerk, helping to keep me meaningful. I’ve gotten wise to this pitfall, so normally I am careful to scribble my name on the bottom line as soon as I enter the room. After that signature, I also sign the patient’s superbill, the MD-HAQ, as well as any lab orders, FMLA (Family and Medical Leave Act) forms, or written prescriptions that need my signature. This morning I told one patient, "I have to sign my name three times before I can sit down." I told another elderly patient that I would try and squeeze her in between the many forms I had to fill out in her 15-minute visit. Many trees are needed to keep the questionnaires coming. This is the burden of meaningful use.