During a daylong listening session sponsored by federal healthcare and health IT officials focused on the issue of reducing clinician burden, healthcare industry stakeholders—physicians, nurses, patient advocates and entrepreneurs—shared a litany of frustrations and complaints about electronic health records (EHRs) systems adding to administrative burden and contributing to physician burnout.
Officials with the Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Health IT (ONC), both within the U.S. Department of Health and Human Services (HHS), got an earful from clinicians and other stakeholders about poor health IT workflows and the challenge of keeping up with government reporting requirements. The listening session took place in person in Washington, D.C., as well as via telephone.
One semi-retired practicing physician said that in the process of adopting health IT and EHRs, the healthcare industry’s focus has shifted from the patients to billing. “I’ve been through four different EHRs in my time, and what we failed to do in all that process, is that we failed to keep patients at the center of that process. At the end of the day, we are either typing or using natural language processing (NPL) or clicking boxes and patients don’t get anything out of that. They get us looking at our computers,” he said. “We have to get back to keeping it simple.”
The physician, who said he has been practicing for 26 years, also said, “Everything we’ve built is about how we get paid and how do we protect how we get paid. I’d like to see us build something in NPL, so that with the aging population, that patient can get that record and have some autonomy and you can give that record to a family member; put that patient at the center of what we are doing.”
Clinicians raised a number of issues related to “note bloat,” the lack of interoperability, inaccurate medication lists and too much reporting. One clinician cited the “tremendous broken promise around interoperability,” as an important issue for the health IT industry to focus on. “The return on investment promised with creating an EHR was that we would finally have data liquidity; the information we needed to take care of patients at the point of care would be available. That has never happened. I’m still exchanging faxes between hospitals and other providers; the electronic transmission of information that was supposed to create a seamless process hasn’t happened.”
One patient advocate, who said she has been living with chronic disease for 40 years, said bluntly, “The systems you are forced to use suck and don't do what they're supposed to be doing.”
Another physician urged CMS officials to simplify reporting requirements: “The right thing to do is the simple thing; focus technology on the data needed for care, it’s not about the secondary uses of data, including reporting to federal agencies. CMS has an opportunity to simplify Meaningful Use for hospitals and an opportunity now to right the ship and look at, are you doing the right thing as opposed to having a lot of checked boxes.”
Based on the comments, it’s clear that many clinicians are fed up with current EHR systems, and many suggested scrapping legacy systems altogether and focusing instead on consumer-facing technologies and open application programming interfaces (APIs). One physician said, “We, as a group, need to think about some of the solutions that are already out there and maximize them. Stop thinking about legacy systems; we don’t need to be here, we can start over. It will be challenging, but where we are right now is a sinking ship situation. We should optimize the solutions used by our patients every day. There are these other programs that we could be utilizing to improve patients’ health and improve the life of physicians.”
One cardiologist noted that the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and the 21st Century Cures Act were steps in the right direction regarding aligning reporting requirements, but more work needs to be done. “There is a lot of complexity that is confusing. MU (Meaningful Use) was rolled into QPP (Quality Payment Program), and other programs that still exist, so it’s incredibly confusing and we use a multitude of standards and requirements that are not aligned. CMS and ONC need to align some of these existing programs to help to reduce administrative burden and the complexity of these programs.”
Opening up the listening session, Kate Goodrich, M.D., chief medical officer at CMS, said the purpose of the public listening session was to gather stakeholder feedback about administrative and reporting burdens from health IT, which will then inform the agency’s efforts to make life easier for clinicians.
“We’ve been trying to engage with our provider and patient and other stakeholder partners pretty intensively to hear from you all about the specifics of the things that CMS could be doing and other parts of the department to reduce administrative burden on providers, while maintaining safety for patients and better health outcomes for patients,” she said.
At the end of the listening session, John Fleming, ONC deputy secretary for reform, said, “We’ve heard your suggestions, and the bottom line is, we want to improve patient care quality and reduced the cost of care, and that’s a difficult equation to come to. Health IT offers a number of potential solutions to our problems, but right now it’s creating a lot of burden.”
Fleming classified the issues into four priorities moving forward—streamlining documentation, getting EHR-based preapprovals for tests, referrals and medications; reducing the burden of quality reporting, and improving prescription drug monitoring programs (PDMPs) for controlled substances.
Andy Gettinger, ONC’s chief medical officer, said, “I don’t believe our work will be done until the EHRs and other health IT tools are things that clinicians who are taking care of patients can’t imagine taking care of patients without, because they need them. We haven’t gotten that sense today. We have work to do, collectively, not just government.”
CMS and ONC officials urged healthcare stakeholders to continue to provide input on clinician burden from health IT by emailing comments to this address: ReducingProviderBurden@cms.hhs.gov.
CMS and ONC officials also highlighted ongoing work to address regulatory and administrative burden, such as documentation requirements, relating to the use of EHRs. CMS officials pointed to the steps being taken as part of the Patients Over Paperwork initiative, such as ending a requirement that doctors re-write medical students' notes in EHRs. CMS officials said CMS Administrator Seema Verma is focused on simplification of documentation requirements, including getting rid of requirements no longer needed and making requirements easier to understand.
A team led by ONC’s Gettinger and CMS’s Goodrich are collecting feedback and suggestions from providers and the team has developed clinician burden workgroups to further investigate the issue. The workgroups focus on topics such as documentation, administrative and reimbursement models, EHR reporting, health IT and user-centered design and non-federal payers and other government requirements. HHS may consider regulation and sub-regulatory measures, Gettinger said.
Goodrich stated that 2018 “is going to be a big year” for sub-regulatory activities.
When it comes to health IT usability, EHR workflows seem to be top of mind for many clinicians. During audience polling on a number of health IT issues, a little more than half of the audience cited alignment of the clinical and EHR workflow as the most pressing EHR usability issue. When asked what ONC should do to help drive usability improvements, close to 60 percent said they’d like to see more substantial changes requiring adherence to certain agreed upon usability standards and best practices.
When asked about the most burdensome aspect of using health IT for clinical care, clinicians and other stakeholders in the audience were evenly split between documentation requirements and lack of interoperability (each cited by about 35 percent of the audience).
The audience also was polled about ways that CMS could reduce EHR-related burden associated with documentation of patient visits for billing. Half of the audience would like to see CMS not require documentation if the information already exists in the record, and about 40 percent would like to see CMS explore alternative documentation strategies for reimbursement which do not rely on prescriptive documentation requirements.