Doctors and nurses often decry paperwork, and for good reason: Some spend almost half their working hours inputting information into the electronic health record, and many say the constant barrage of paperwork causes frustration and burnout. So I wasn’t surprised when I asked the medical director of a Baltimore clinic when he manages to complete a particular form for his patients and he said, “After the workday,” eyeing the paperwork piling up on his desk. Though I did wonder how long after the workday he meant.
The form I asked about is the Maryland Prenatal Risk Assessment (MPRA). It’s one of many that medical providers in the state are required to fill out for their pregnant patients whose care is covered primarily by Medicaid. But in the city of Baltimore, 20% to 30% of those patients never have an MPRA completed for them.
Missing a few forms may not seem like a big deal for the clinics or providers. But it is for their patients and their babies: When a provider doesn’t submit an MPRA for a Medicaid-covered pregnant patient in Baltimore, her child is five times more likely to die before birth or in the first year of life than babies whose providers submit the form, according to an analysis by the Baltimore City Health Department.
How can the MPRA so dramatically affect babies’ well-being? This unassuming form not only helps providers create a plan of care for their patients but it also kicks off care coordination processes at local health departments and managed care organizations. Care coordination helps expectant parents access services like the Special Supplemental Nutrition Program for Women, Infants, and Children; home visits from nurses and social workers; safe cribs; education on everything from safe sleep to how to navigate Medicaid; and much more. In other words, it unlocks the time and personal attention that doctors can’t give patients on their own.
The MPRA is not the only form that fulfills this function, but it offers an excellent case study. Across the country, thousands of professionals are supporting patients outside of clinical settings thanks to the very paperwork that plagues physicians. Referrals similar to the MPRA in form and function have been used in Florida, Indiana, Missouri, and New Jersey.
It would be a tall order to claim that the MPRA form itself saves lives, but the services to which it links patients are proven to improve outcomes. Completing the MPRA is a five-minute task that appears to trigger life-changing follow-up. That’s what prompted me to find ways to get medical professionals to submit it more often.
Last year, my colleagues and I at ideas42 partnered with the B’more for Healthy Babies initiative to learn why the MPRA was falling through the cracks. BHB, led by the Baltimore City Health Department and the Family League of Baltimore, was founded in 2009 to improve maternal and child health in the city. It has had considerable success: From 2009 through 2017, the infant mortality rate fell by 36% across all births, and the disparity in deaths between black and white infants dropped by 40%. But B’more for Healthy Babies isn’t resting on its laurels, especially since the infant mortality rate in Baltimore still substantially outstrips the average rate across the U.S.
In visits to several prenatal care practices, we encountered a variety of reasons for missing MPRAs. The problem with getting more providers to fill out this form regularly exemplifies many of the issues plaguing health care systems across the country.
First, the MPRA has historically been a hard-copy form, not a digital one. Paper forms incur data entry costs, errors, and duplication of work. Since the HITECH Act of 2009 requires meaningful use of electronic medical records, completing the paper MPRA represented duplicated effort, which often felt like a waste of precious time to prenatal practice staff. And while each practice we visited kept completed MPRAs on file, almost no one could immediately tell us how many of their pregnant patients’ charts included MPRAs — or didn’t. While migrating forms like the MRPA into digital formats may have a high up-front price tag, I believe the long-term cost savings and improved patient and provider experience would make the move worthwhile.
Second, at the busiest practices, a significant deterrent was that providers simply didn’t have the time or attention to devote to paperwork. At some practices, the MPRA was absent in new staff training, or health providers perceived completing it as less important to their jobs than delivering clinical care. This isn’t terribly surprising: A key reason that medical professionals on the whole dislike paperwork is that it takes away from the time they spend with patients. And it’s true — the health system as it stands asks physicians to sacrifice time, either their own or their patients’, for what may feel like a thankless data-entry exercise. But when we see the impact of the MPRA on infant lives, restructuring health care institutions to provide more resources for care sounds like a much needed — if hefty — endeavor.
Documentation isn’t a mere distraction from care: It’s a way to expand the caregiving team for patients with complex lives beyond the exam room. Health care leaders owe it to their patients to think carefully about how to reduce the pressure of data entry on providers’ time and attention because it is good for patients and providers — and throwing out the paperwork simply isn’t an option when many health forms have real impacts on patients.
Instead of vilifying paperwork, we need to make it better, closing the gap between the documentation patients need and what doctor’s offices can provide.
Erin Sherman is a vice president at the behavioral design lab ideas42, where she applies behavioral science to problems in health care, sustainability, and civic engagement.