By Michael Burger, Practice Lead, EHRs and EDI

Physicians today face many realities in their practices that often create frustration— burdensome administrative tasks, complex clinical care, tightened reimbursement, required quality reporting and regulatory requirements, just to name a few. Health information technology (health IT) and electronic health records (EHRs) may also be contributors to physician frustration; but can also be part of the solution. This issue was explored in a new final report from the Office for the National Coordinator for Health Information Technology (ONC), which fulfills a requirement of the 21^st Century Cures Act. This new strategy was developed in collaboration with the Centers for Medicare and Medicaid Services (CMS).

POCP’s Perspective on Business Impacts of the CMS and ONC Rules

The framework does a good job of identifying challenges and providing strategies to reduce administrative burden related to use of EHRs and health IT by clinicians. Its suggested solutions are not prescriptive. Rather, they are fairly high level and aimed at being achievable in a 3-5-year window. Elements of this framework will be implemented through the recently enacted CMS and ONC Final Rules, which we will cover in more depth in an upcoming article.  To learn more about business impacts of the recent rules, watch POCP’s recent virtual session.

Opportunities to Reduce Physician Burden

ONC focused on the following four challenges and provides recommendations for improvements:

• Clinical Documentation
• Health IT Usability and the User Experience
• EHR Reporting
• Public Health Reporting

I will leave it to others to detail the specific findings laid out in the report. I recommend reading the eHealth Initiative’s executive summary which is broken down by specific recommendations and actors. In this blog, I’d like to give a few ideas of additional action steps that the government, EHR vendors and physicians can take to respond to the government’s recommendations.

1. The federal government. Federal government activities are the focus of this report, as required by the 21^st Cures Act directive. Opportunities for how the government can mitigate physician burden are called out, but here are a few more.

• • Simplify reporting requirements. One recommendation is to leverage health IT functionality to reduce administrative and financial burdens associated with quality and EHR reporting programs. The myriad of clinical quality measures (CQMs) and the complexity of extracting, calculating and reporting them places a significant administrative burden on providers. Synchronizing CQMs across the various programs to ensure that the data gathering is concise and consistent will reduce EHR-related burden.  And enabling application programming interfaces (APIs) for reporting of the data “at the press of a button” should ease the financial burden of complex calculations and data transmission.
  • Streamline documentation requirements. Changes to E & M (evaluation and management) codes as an action area are in the report. These are the current procedural terminology (CPT) codes that describe the patient-physician encounter and are essential for billing. EHRs have been designed to enforce the documentation requirements to justify these codes for billing. CMS has been working to streamline E & M codes and significantly reduced the number of codes, and the amount of documentation required in the last fee schedule. That is certainly a step in the right direction and hopefully will continue--as well as serve as an example of what can be done to meaningfully reduce documentation requirements in other Medicare programs.
  • Try to keep cycles at a minimum. New and updated requirements for EHR certification, CQMs and incentive program reporting incrementally pile on every year, and vendors scramble to keep up. Keeping those updates and new requirements to a minimum — and perhaps on a regular periodic update cycle — would go a long way to enable vendors to improve and streamline workflows, and give physicians a chance to adjust. Giving vendors a breather from the steady flow of requirements would allow time for innovation and to address the “too many clicks” criticism from physicians.
  • Address electronic prior authorization (ePA). According to the report, “clinicians have also identified documentation requirements for items and services associated with prior authorization and ordering for certain items and services as significant sources of burden.” The government has already taken a major first step by requiring the use of the electronic prior authorization standard from the National Council for Prescription Drug Programs (NCPDP) for Medicare Part D. This will help drive private insurers to use a more automated process. Despite the progress that has been made to streamline the process, physicians still must answer the prior authorization questions, even though the process to submit them is automated. The government should continue to drill down to minimize and standardize the questions that need to be answered for Medicare, Medicaid and private payers for ePA.

2. Vendors. There are various suggestions aimed at EHR developers, such as improving the user-friendliness of interfaces and standardizing how clinical content is presented. So how can vendors respond to these recommendations beyond specific changes to their products? Here are two ideas.

• • Internalize the recommendations. Vendors tend to wait for mandates to develop strategies to act on. To be sure, the proposed recommendations are just that: recommendations, and they have no teeth. However, they represent an opportunity to know where CMS and ONC are going, long before rulemaking turns these proposals into mandates. They also dovetail with the government’s other interoperability efforts. Internalizing some of these recommendations into strategic planning will enable vendors to be proactive instead of reactive, and potentially get a leg up in the market.
  • Revamp training strategy. EHR vendors often craft training curriculum in a “brain dump” methodology, trying to teach new users the entire EHR all at once. The challenge to this methodology is that clinicians can’t or won’t devote the time required to attend the full session. And, because EHR workflows are unfamiliar to new users, the trainees don’t know the right questions to ask. As an industry, EHR vendors should work to create more widely accessible learn-as-you-go training opportunities.

3. Physicians. Physicians, of course, are at the heart of the issue. While many of the proposed recommendations are outside of their purview, there are still some things they can do on their own. For example:

• • Get needed training. ONC’s Report called out the lack of training as an underlying source of physician frustration. Physicians are challenged by constant changes in technologies and data collection and reporting requirements from payers and government agencies. Their inability to use their EHRs efficiently is perceived to result from the inferiority of the interface, when lack of training is a major culprit. In fact, training is often cut from recommended vendor implementation plans, citing practice bandwidth or budget concerns. The physician community needs to commit to following the vendors’ recommended plan to ensure use of optimized workflows. Well trained EHR users, utilizing optimized workflows will go a long way to improve perceived usability and the user experience.  Government incentives to encourage completion of appropriate EHR training might be a possibility to spur such an effort.
  • Take matters into their own hands. Physicians and their staff should take a long, hard look at the workflows in their practices. Armed with this information, they can take action to mitigate time consuming, redundant and unnecessary EHR-related activities. The American Medical Association (AMA) can help with a free, online program called the AMA STEPS Forward™ that can help doctors learn how to identify challenges and create a standardized organizational process to identify and eliminate time-wasting activities in their day-to-day, electronic work life. Included is a list of key steps to eliminate time-wasting EHR activities, which in turn reduce administrative burden. One health system took that to heart. Its physicians and other clinicians found more than 300 EHR-related activities that potentially could be eliminated in just one year.
  • Get ahead of the EPCS curve. The increased adoption of electronic prescribing of controlled substances (EPCS) was called out as an area of strategic importance. Mandates are often perceived as burdens for physicians. Instead of looking at mandates only in terms of technology challenges, physicians need to look at the benefits to the workflow process. And get ahead of the curve to avoid inevitable delays by waiting till the last moment to take action toward compliance by the mandate deadline. Traction for EPCS has been building slowly, driven primarily by laws and regulations in some states. Currently, 12 states have some form of EPCS mandate in effect and 16 other states have passed legislation mandating EPCS but with effective dates ranging from 7/1/2020 thru 1/1/2022.

But the need to adopt EPCS will change radically next January 1, when EPCS will be required for Medicare Part D controlled substance prescriptions. Rather than have two sets of controlled substance prescribing workflows — one for Medicare patients using EHRs and a paper-based one for other patients — physicians will abruptly convert to an all-electronic prescribing process. EHRs are ready, but there’s a catch. EPCS has strict credentialing requirements put in place by the Drug Enforcement Administration, so it takes time to credential and enroll individual prescribers for EPCS. I’m betting there will be a mad dash at the end of the year for physicians to become EPCS certified. This is bound to create some unhappy campers in the physician community unless they get ahead of the curve and get certified sooner rather than later. This is a process problem, not a technology problem.

Want to know more? Point-of-Care Partners and I have been heavily involved in how the government, EHRs and physicians can mitigate physician burden. I’d be happy to provide more detail. And I’d love to hear what you think. Reach out to me at michael.burger@pocp.com.