The burden of bureaucracy in medical practice has long been a problem and technology is not yet making it any easier
Red tape and bureaucracy have long been a considered a menace to medicine. The profession says the problem is as acute as ever.
There is the driver’s licence form that asks for the patient’s name to be entered three separate times. There is the form that arrives in the mail but still requires the clinician to enter their postal address. There are DVAs, DSPs and ACATs. And then there is the PBS Authority system and the estimated 2 million unnecessary phone calls from doctors it entails every year.
In the United States, some doctors now pay medical scribes to tail them during consultations, keeping the medical notes and completing necessary forms in order to allow the clinician to focus on face-to-face health care. It’s not yet happening in Australia, but the time and cost of endless box-ticking and form-filling has engendered serious concern for the impact this is having on patient care.
In one recent instance, it all became too much for a rural general practitioner with a bulk-billed client list heavy with those suffering drug and alcohol addictions and the morass of associated morbidities. She took down her shingle and closed her practice.
Emeritus Professor of Public Health and Community Medicine at the University of New South Wales, Dr Ian Webster, says there were complications involved, but it was an example of the current burden of bureaucracy in general practice.
“Most doctors, even the experienced doctors, get fed up with it. They feel constantly under threat by the regulations and being under surveillance”, Dr Webster says.
“Of course, there are people who do the wrong thing, but the vast majority of people are doing the right thing.
“The consequence is that they get irritated. They get cross and they don’t want to deal with these things. They disengage.”
In the example he cites, the required paperwork associated with the doctor’s many complex patients itself also became a serious deterrent to other doctors taking on their care.
“Of course, then all of these complicated people have to find other doctors and they don’t want to see them — thanks very much!”
Dr Webster’s anecdote is an acute example of the consequences of GPs bearing the brunt of the health system’s red tape requirements.
A 2013 Australian Medical Association (AMA) survey on red tape found that many GPs now devote 9 or more hours each week to administrative processes.
According to separate results recently released from the long-term Bettering the Evaluation and Care of Health (BEACH) survey, on average, GPs spend 2.5 hours each week on non-billable patient care, adding up to $15 000 lost income per year.
As far back as 2003, and again in 2006, the Australian Productivity Commission recommended that the bureaucratic processes and requirements be amended to increase system efficiency. Progress has been slow, but late last year the new Abbott government made some small moves towards trimming bureaucratic duplication, including enabling physicians to dispense medicines from bedside medical charts without needing to issue a prescription.
“That’s just fantastic. It should have been done long ago to help facilitate care”, AMA federal president Dr Steve Hambleton says.
He says the need to reduce unnecessary red tape underlies all AMA policy recommendations and any consultation it does with government.
To that end, the organisation recently called for significant changes to the PBS Authority system, chronic disease management and Medicare provider numbers in its submission to the National Commission of Audit, which was set up to trim the federal bureaucratic budget.
And Dr Hambleton is cautiously optimistic that Minister for Health Peter Dutton is listening.
“We’ve made direct representations to the Commission of Audit about things like the authority system, and the government is very interested in other areas where they can undo red tape involving medical practice and, in particular, general practice.”
Too much authority
Despite recent changes to try to improve the efficiency of the system, the PBS Authority system — entailing roughly 500 000 doctor phone calls each month — remains one of the most frustrating bureaucratic bugbears for the profession.
A call for its removal led the AMA’s Commission of Audit submission.
“We quantified in our submission that there are 2 million phone calls a year that don’t need to be made”, Dr Hambleton says.
“It’s an enormous waste of time when GPs can increase their productivity by directly seeing patients, not waiting on the phone for someone to approve something that’s routinely approved.”
The problem is not confined to general practice. It affects anyone who interacts with the PBS, from palliative care clinicians to anaesthetists, oncologists and intensive care specialists.
However, early indications suggest that the current federal government may address this problem. While cautioning that a positive outcome should not be assumed, Dr Hambleton says he’s encouraged by the fact that there is now a minister who is seriously looking at the problem.
“We’ve got some sensible suggestions coming out of the AMA therapeutics committee about which particular drugs pose low risk, we’ve got evidence from the drug utilisation subcommittee that there’s not an explosion of misuse of drugs when they move from Authority to General Benefit, and all of those ducks are lining up in the right direction”, he says.
Technology — problem or solution
In theory, many of the inefficiencies that riddle the system could be solved by technology. Already, software templates are making form completion much less onerous for many practices.
However, the personally controlled electronic health record (PCEHR) continues to cause more problems than it solves.
“Signing up for the PCEHR as a GP is like doing a triple somersault with a twist”, Dr Hambleton says.
“If you don’t land properly, you have to start again.”
Senior BEACH researcher and deputy director of the Family Medicine Research Centre at the University of Sydney’s School of Public Health, Dr Joan Henderson, says that the system needs to recognise the time involved in asking GPs to become processors.
“If you want them to tick every box in the desktop software about what they did for the patient and what was the result of each test, to find out what the care processes are and what the outcomes are, you have to consider the time that’s involved in that”, she says.
Both Dr Henderson and Dr Webster believe that an increased involvement of GPs and other doctors in the development of regulation and data collection systems would be a valuable step towards to reducing red tape to its bare essentials — a move towards collecting only the information that will produce a meaningful outcome.
BEACH began monitoring non-billable time 2 years ago in response to requests from the AMA and the Royal Australian College of GPs.
Dr Henderson laughs at the irony that monitoring the non-billable time of GPs has required her and her fellow researchers to ask them to fill out still more forms and says that the GPs are being incredibly generous in taking part in BEACH.
The 2013–14 results will be available later this year and Dr Henderson says non-billable time is unlikely to be any less than in previous years given the growing demands for monitoring in general practice. BEACH’s previous results have shown that non-billable time also increases with the age of the patient, so it looks likely that red tape will continue to loom large in medicine for a long time to come.
Practice perfect protocols
General practitioner Dr Harry Hemley declares he is in a good mood when we speak, partly due to the fact the bureaucracy of practice falls dramatically over the summer period.
“I can actually see patients and have a peaceful existence”, he says.
The phone at his Melbourne practice goes quiet over summer when compared with the rest of the year, as the calls from the various levels of government temporarily stop.
“All the bureaucrats have gone on holidays. It just makes life so much easier.”
The former president of the Victorian AMA has been campaigning against red tape for years. He says that it’s not just his time and his GP colleagues’ time that is wasted on filling out forms and answering calls — the entire practice is involved.
“Our phones run hot, with people ringing up all the time from various government departments, patient carers, caring organisations and so forth.”
To help cope with the demand, over time the practice has devised a set of protocols on who can answer particular calls and fill out particular forms. Patient confidentiality requirements have played a big role in determining who can do what. As a result, Dr Hemley says that the practice’s GPs now rarely have to speak to a bureaucrat on the phone themselves.
The introduction of smart forms by the Victorian Government has also gone some way to reducing the time required to meet red tape requirements. And despite current frustrations, Dr Hemley says he is optimistic that ultimately the personally controlled electronic health record will dramatically reduce the amount form-filling and box-ticking required.
“But I’m not holding my breath.”