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Same Day That Final Rules Appear, ONC Hears About Clinical Documentation Burden

October 6, 2015
by David Raths
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537 computer clicks to fill out one nursing admission assessment

On Oct. 6, the same day that CMS would later unveil its EHR Incentive Program final rules, a joint meeting of the federal Health IT Policy and Health IT Standards committees focused on health IT’s role in support of payment reform initiatives. Committee members, however, raised concerns about the clinical documentation burden imposed by the plethora of quality reporting programs. In fact, a few concerns raised during the meeting are addressed in some of the efforts to streamline quality reporting mentioned in the final rule documents.

Kate Goodrich, M.D., M.H.S., director of the quality measurement and value-based incentives group at CMS, gave a presentation about the request for information CMS has released regarding the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which will change how Medicare pays physicians. MACRA replaces the Sustainable Growth Rate methodology, which has caused physician payment uncertainty for more than a decade. One part of MACRA, the Merit-based Incentive Payment System (MIPS), includes consolidated aspects of the Physician Quality Reporting System (PQRS), the Value-Based Payment Modifier (VM), and the Medicare Electronic Health Records (EHR) Incentive Program.

But the providers on the committees asked if federal officials are aware of the huge impact on clinicians of documenting quality for the alphabet soup of acronyms already in place. Patricia Sengstack, chief nursing informatics officer at Bon Secours Health System, said that many nurses in her organization complain that their nursing admission assessments take almost two hours to complete for each patient. “I had a student count how many clicks it took to fill it out, and if you filled out everything, the total comes to 537 clicks,” she said. These are for meaningful use, ACO measures and other programs. She asked if there were any plans at the federal level to shrink all the required documentation.

Karen DeSalvo, M.D., national coordinator for health information technology and acting assistant secretary for health at the U.S. Department of Health and Human Services, responded that among other things, HHS needs “to see if there are there ways we can streamline quality reporting to make it seamless so there is e-quality measurement and think about the documentation burden component of that so we are linking these clicks to outcomes.”

Goodrich added that the documentation burden is an issue CMS has heard a lot about. “We have tried to address that in a few ways,” she said, “but perhaps we should set specific targets. With meaningful use measures and what is required for documentation, in our proposed rule we have proposed a significant reduction in terms of what has to be documented. We are trying to be responsive to exactly what you are saying,” she said. On the quality measure side, one of the things we absolutely could have done better in Stage 1 and Stage 2 of meaningful use is to have involved the front-line providers — meaning the nurses who actually do the entry of data as well as the front line physicians and EHR vendors — in development of measures with an eye toward not only having the right kind of measures, but ensuring that the logic relates to the work flow is created in such a way that we minimize that burden, and we did not do a very good job of that in the first couple years. Part of that is because we took administrative claims measures and retooled them.”

Goodrich said one thing CMS was thinking about as it was designing the MIPS program is that that the way providers interface with CMS to report on all these programs is burdensome. “They have to go multiple portals to enter information for multiple programs,” she said. “If they are reporting on quality measures, we think we need to move away from claims quality measures, and incentivize moving into more registry- and EHR-based submission of data. But we are also trying to think about how we create a new program that fundamentally changes how clinicians interface with CMS to meet the requirements they need to meet.” She said CMS wants to leverage what is captured through the EHR so data for quality reporting and meaningful use is streamlined into a single interface. “That is our goal. We have defined that as our ideal state. I am not sure we will get there immediately. But the law provides us with more flexibility than our statutory requirements under the PQRS program.”

Devin Mann, M.D., the associate chief medical innovation officer for Innovation and Population Health at Boston Medical Center, said perhaps CMS should do time studies and that new quality measures introduced should be required to demonstrate value without putting additional drag on the system. “Until it is that concrete, I think it would be a very challenging argument, no matter how simple the interface is, to get CMS the data and ensure the work to get the data was not actually more burden.”

Stanley Huff, M.D., chief medical informatics officer for Intermountain Healthcare in Salt Lake City, expressed his disappointment that the new value-based payment schemes will continue to require the use of certified EHR technology, which he described as “sucking the blood out of innovation and usability.” But given that certified EHR provisions are going to be a part of the scheme, he suggested focusing on interoperability criteria only and taking away burdensome functional criteria.

Goodrich responded that CMS will continue to work with ONC on certification and will have opportunities to make changes as they go forward.