January 1, 2012 brought another layer of documentation mandates to every office visit progress note. Meaningful use regulations added to chronic pain regulations in Washington have changed the context of many patient visits. As of Jan 1 of this year I feel like I’ve crossed over the edge and now have to spend more time as a clerk than as a physician interacting with my patients. I’ve succumbed to well-intended, government-imposed veiled threats and financial incentives, you could say fear mongering and bribery by our governments. This has led me to agree to yet more documentation in every visit to show that in the case of pain management that I am complying with many abuse prevention practices, and in the case of Medicare my use of an electronic medical record shows meaningful use. I guess this is as opposed to meaningless use.
In the meaningful use arena the problem is in how the regulators define meaningful use. At our office we have had an EMR since 1997, and take expend considerable effort to make very meaningful use of the information. We have a virtual disease management registry so that we can improve our efforts to assure our diabetic, hypertensive and hyperlipidemic patients stay on track to maintain good control of their health. We make attempts to get patients in for preventative care visits. We use printed prescriptions to reduce errors with hand written prescriptions. Unfortunately in order to demonstrate the government definition of meaningful use, and qualify for a financial reward for meaningful use from Medicare, I need to do some other things with the EMR. These involve taking time during patient visits to generate documents to pass out to patients at the end of the visit. To a bureaucrat these may seem important, and maybe they are, but to me they mean I have to spend 2-3 minutes of each visit assuring that the patient’s gets a printed medication list and problem list, and then typing a visit summary and directions to give the patient. This means that the note for the patient encounter has to be complete or nearly complete while they are in the exam room. On a busy day I in the past have chosen to complete these at the end of the half-day so that later patients do not need to wait as long for me to get to their visit. For some visits I agree that these are important. For other visits they are just extra work that either takes time away from direct patient – physician interaction or puts me behind in my schedule and late for the next appointment and every subsequent appointment that half day.
In the case of pain management I have done the mandatory 4 hours of additional education on the use of pain medications. That was the easy part. Now I need to document at each visit that I am abiding by the state regulations. The concept of these is right on target, but the details of the regulations is onerous. Now for every office visit with patients on chronic opioid pain management we need to use specific tools to assess the individual patient for depression, opioid abuse risk, degree of pain control, level of functionality and be sure that every 6 months we have a new 20 point pain medication agreement explained, signed and documented in the chart. After this if there is any time left we can actually assess the problem causing the pain and see if there is anything to do to help with that.
These new regulations are on top of the complicated set of rules for what we need to document in order to show to the insurance company that they should pay me and what I need to document to give our lawyers enough information to defend me if I am sued. Oh, I also want to make a note that serves to help me or anyone else provide good continuity of care.
If I sound cynical it is not accidental. I feel like the newest regulations have gone over the top, and now every day I spend more time documenting care than I do providing care. It’s silly, and I predict that these efforts will turn out to be counterproductive. Patient satisfaction and actual quality of care will be lower as a direct result of government regulations designed to improve quality of care. There you have it, my experiences from my first 6 weeks of daily work under the 2012 Washington state chronic pain management regulations and the Medicare meaningful use incentive program.
As president Reagan famously said, “The most terrifying nine words in the English language are: ‘I’m from the government and I’m here to help .’ ”