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Administrative Work Consumes U.S. Physicians' Time and Erodes Morale

Electronic health records increase doctors’ bureaucratic burden

by Physicians for a National Health Program
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Electronic health records contribute to physician workload and job satisfaction.The average U.S. doctor spends 16.6 percent of his or her working hours on non-patient-related paperwork, time that might otherwise be spent caring for patients. And the more time doctors spend on such bureaucratic tasks, the unhappier they are about having chosen medicine as a career.

These are some of the findings of a nationwide study by Drs. Steffie Woolhandler and David Himmelstein, internists in the South Bronx who serve as professors of public health at the City University of New York and lecturers in medicine at Harvard Medical School. The study was published this week in the peer-reviewed International Journal of Health Services.

Woolhandler and Himmelstein analyzed confidential data from the 2008 Health Tracking Physician Survey (the most recent data available), which collected information from a nationally representative sample of 4,720 physicians who practiced at least 20 hours per week.

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They found that the average doctor spent 8.7 hours per week, or 16.6 percent of their working time, on administration. This excludes patient-related tasks such as writing chart notes, communicating with other doctors and ordering lab tests. It includes tasks such as billing, obtaining insurance approvals, financial and personnel management, and negotiating contracts.

In total, patient-care physicians spent 168.4 million hours on such administrative tasks in 2008. The authors estimate that the total cost of physician time spent on administration in 2014 will amount to $102 billion.

Career satisfaction was lower for physicians who spent more time on administration. “Very satisfied” doctors spent, on average, 16.1 percent of their time on administration. “Very dissatisfied” doctors spent 20.6 percent of their time on such tasks.

Among various specialties, psychiatrists spent the most time on administration (20.3 percent), followed by internists (17.3 percent) and family/general practitioners (17.3 percent). Pediatricians spent the least amount of time (14.1 percent) on non-patient-related administrative tasks and also were the most satisfied group of doctors.

While solo practice was associated with more administrative work, small group practice was not. Doctors practicing in groups of 100 or more actually spent more time (19.7 percent) on such tasks than those in small groups (16.3 percent).

Interestingly, the authors note that physicians who used electronic health records spent more time (17.2 percent for those using entirely electronic records, 18 percent for those using a mix of paper and electronic) on administration than those who used only paper records (15.5 percent).

“Although proponents of electronic medical records have long promised a reduction in doctors’ paperwork,” they write, “we found the reverse is true.”

The authors cite data showing that physicians in Canada spend far less time on administration than do U.S. doctors, and attribute the difference to Canada’s single-payer system, which has greatly simplified billing and reduced bureaucracy.

They point out that the only previous nationally representative survey of this kind was carried out in 1995, and that study showed that administration and insurance-related matters accounted for 13.5 percent of physicians’ total work time. Other, less representative studies, also suggest the bureaucratic burden on physicians has grown over the past two decades.

“American doctors are drowning in paperwork,” said lead author Dr. Woolhandler. “Our study almost certainly understates physicians’ current administrative burden. Since 2008, when the survey we analyzed was collected, tens of thousands of doctors have moved from small private practices with minimal bureaucracy into giant group practices where bureaucracy is rampant. And under the accountable care organizations favored by insurers, more doctors are facing HMO-type incentives to deny care to their patients, a move that our data shows drives up administrative work.”

Dr. Himmelstein commented: “Our crazy health financing system is demoralizing doctors and wasting vast resources. Turning health care into a business means we spend more and more time on billing, insurance paperwork and the bottom line. We need to move to a simple, nonprofit national health insurance system that lets doctors and hospitals focus on patients, not finances.”

“Administrative work consumes one-sixth of U.S. physicians’ working hours and lowers their career satisfaction,” Steffie Woolhandler, M.D., M.P.H., and David U. Himmelstein, M.D. International Journal of Health Services, Vol. 44, No. 4.