Canada’s war on physician paperwork

Physicians told the CMA/CFIB Losing Doctors to Deskwork study that they spend nine hours per week on administrative tasks, totalling 42.7 million hours annually across the country. They categorized close to half of that as unnecessary work that could be eliminated or delegated to someone else.

A whopping 93% of the 1,924 doctors participating in the study agreed that the time required to complete administrative work disrupts their work-life balance; 95% agreed that unnecessary paperwork reduces professional fulfillment; and 90% concurred that clinical documentation contributes to burnout. More worrying, over half of physicians said they intend to reduce their clinical hours over the next two years; one in four is considering leaving medicine or retiring earlier than planned; and more than one-third said they would discourage medical students from entering their specialty because of the administrative burden.

Fortunately, the extent of the problem appears to have been heard, and solving it is top of mind for governments, health authorities and technology entrepreneurs. Federal legislation requiring software vendors to comply with interoperability standards is in the queue, artificial intelligence is revolutionizing documentation, inbox management solutions are easing cognitive load, e-referral and central intake are streamlining the referral process and intensive lobbying is underway to simplify, eliminate or standardize the many disability and insurance forms doctors are required to fill out. Even better, technology just around the corner will be able to fill them out automatically.

Forms and more forms

Seventy-eight per cent of doctors responding to the CMA/CFIB study ranked disability and insurance forms, along with health-system processes such as the ordering of tests and referrals as the highest-ranking activities contributing to administrative burnout.

They ranked the federal government’s 16-page disability tax credit (DTC) application as the most burdensome form they have to deal with, complaining they see an average of more than 32 of them each year and that it takes them an average of 36.6 minutes to fill out. The DTC was followed closely by private insurance forms that doctors see an average of 54 times per year and take an average of 28.9 minutes to fill out. Family doctors also have to contend with an average of 136 sick notes per year and 14 Canada Pension Plan disability benefit forms that take 43.3 minutes to complete. To add insult to injury, doctors receive no compensation for close to half of all this form filling.

However, intensive lobbying by the CMA, the CFPC and other healthcare organizations appears to be working. In April, the federal government announced several changes to the application process for the DTC, expanding the number of allied health professionals permitted to certify disabilities and reducing the requirement to certify an individual’s impairment as severe and prolonged for Alzheimer’s, cystic fibrosis, severe forms of sickle cell disease and 40 other conditions. The CMA is also advocating for self-attestation by applicants with physician sign-off, recognition of eligibility assessments for provincial disability support programs, expansion of the simplified, two-page renewal form currently being piloted in Manitoba, compensation for filling out the form and the eventual adoption of an honour-and-audit model, replacing mandatory health professional certification for every application.

The CMA has also worked with the Canada Life and Health Insurance Association to advocate for a standardized, one-page, two-sided form that is rolling out to all their members and has successfully lobbied most provinces and territories to reduce the number of sick notes employees are required to obtain for short term illnesses.

These efforts will reduce the amount of time doctors spend filling out forms, “but I don’t think we will ever get rid of the administrative burden because we still need to collaborate with our colleagues and teams,” said CMA president Dr. Margot Burnell. “We will still need to provide documentation to access drugs that are effective but costly. We will still need to make referrals for caregiver support, but the more standardized it is and the simpler it is, the better.”

AI scribes

According to the CMA/CFIB report, 28% of physicians are using an AI scribe for documentation and report saving an average of 64 minutes per day. Another 42% of physicians expressed an interest in adopting the technology, but AI scribes can do much more than produce a SOAP note.

Dr. Noah Crampton, CEO of Mutuo Health, one of the leading AI scribe vendors in Canada, notes that, “AI is accelerating quickly and competition is hot, so we keep adding more features and functionality.”

Several additional functionalities, including billing code determination, referral processing and even the filling out of insurance and disability forms based on both the interaction between doctor and patient during an appointment as well as the content of the patient chart are in beta testing and due for wider release by year end.

Dr. Crampton, who has a master’s degree in health informatics from the University of Toronto, is also keen on AI evidence lookup, which uses UpToDate and OpenEvidence to automatically suggest clinical questions doctors can ask their patients in real time based on the content of the interaction and the patient chart.

Mutuo Health can also process prescriptions and both lab test and diagnostic imaging requisitions but wants to be cautious about releasing this functionality. “Even if a competitor gets to market before us, I think it’s important that we get it right,” said Dr. Crampton.

The referral burden

Referrals to specialists are singled out in the Losing Doctors to Deskwork report as a top-ranked health-system process contributing to the administrative burden in primary care. According to Ted Alexander, Amplify Care’s vice-president, partnerships and clinical innovation, doctors using traditional referral workflows complain about identifying the most appropriate specialist to send a referral to and transferring clinically relevant information from their point-of-care system to the referral note. They have no knowledge of specialist wait times or sub-specialties and they aren’t always certain that a faxed referral was successfully received and accepted. The patient information provided in the referral note may not be sufficient for the specialist, so instead of a simple “do it and forget it” task, a referral can easily get bogged down in repeated phone calls and faxes back and forth. In the worst-case scenario, there’s a risk of patient harm if a specialist is on sabbatical or the faxed referral is never received and there is no followup.

Amplify Care (in its former branding as the eHealth Centre of Excellence) pioneered an e-referral network using OceanMD technology in the Kitchener-Waterloo area of southwestern Ontario that has expanded across the province and to other jurisdictions across the country. It still only accounts for 1.3 million of Ontario’s total volume of 9.5 to 10 million referrals processed annually, admitted Alexander.

E-referral is easier and more efficient to use because it provides wait-time and sub-specialty information. It launches within the patient chart and automatically populates standardized, specialty-specific referral forms with patient and provider information. It also allows a family physician to append other information the specialist requires from the patient chart and enables messaging between family physician, specialist and patient so everyone is in the loop and knows what’s happening.

In Ontario, OceanMD’s technology is integrated with most EMRs and two-thirds of family physicians are on the e-referral network. However, only one-third of specialists have access to it, according to Alexander, because many specialists are hospital-based and not all hospital information systems are integrated with OceanMD’s technology.

Alexander points to Thunder Bay Regional Health Science Centre’s Surgical Central Intake system that uses an integration of Novari Health’s central intake technology and OceanMD’s e-referral solution as a model for the rest of the province. “If you’re a doctor in Thunder Bay or anywhere in northwestern Ontario, you can initiate a referral inside your EMR by using Ocean to pick a specialist you want or use central intake,” said Alexander. As part of its Patients Before Paperwork initiative, Ontario Health has executed a multi-year agreement with Novari to extend its central intake solution to other regions of the province, which will ultimately allow all referrals to be processed electronically.