Throughout the week at HIMSS18 in Las Vegas, John Fleming, M.D., deputy assistant secretary for health technology reform at ONC (the Office of the National Coordinator for Health IT), has been making the rounds, speaking mostly about how federal officials can jointly work with the private sector to reduce the burden that IT puts on clinicians.
Dr. Fleming—a former Congressman and a practicing family physician for nearly 40 years—when speaking to health IT press this week, noted a few times that more and more studies that have recently come out serve as evidence that doctors are spending far too much time on documentation and data entry as opposed to caring for patients. And to make matters worse, said Fleming in the media briefing, the quality of the data is often poor. “That’s the most sensitive point—documentation. Doctors are trained to document for pay; the more you document, the more you get paid. But oftentimes, the quality of the document goes down in that case,” he said.
After the media session, Fleming sat down with Healthcare Informatics Managing Editor Rajiv Leventhal to discuss his role in the government, where things stand on reducing clinician burden, and why he thinks patient empowerment is so important to fixing healthcare. Below are excerpts of that discussion.
Last year, right around this time, when it was reported that you would accept this role in the government, there was some uncertainty about your position. Can you explain what you were brought into do as deputy assistant secretary for health technology reform?
ONC breaks down into three missions: one is the carryover from HITECH, so continuing the [EHR] certification program, meaningful use and so forth; the second is interoperability and stopping information blocking; and the third is to relieve clinician burden. The last two have been called out in the 21st Century Cures Act.
My area is the provider burden [part], and I have a background that’s unique for that. I have been a practicing family doctor for nearly 40 years, but also someone who was an early adopter of EHRs, going back to 1997. We were paperless within two years after deploying the EHR [at that time], and in all, we implemented three systems in tandem. I also have experience in building companies going back to the mid-1980s, and at that time I was able to appreciate what technology could bring to the table when it comes to efficiency, the transfer of information, and transactions.
Papers and op-eds are coming out, almost every week, expressing the large burden that EHRs have put [on doctors]. This research has shown that 50 percent to two-thirds of a provider’s day is spent on paperwork or EHRs. Physicians and others are not functioning at the top of their licenses, and there is pent-up demand in this country since doctors are spending half their time doing non-doctor things.
I lead four workgroups, which are a collaboration between CMS [the Centers for Medicare & Medicaid Services] and ONC, to address what the underlying root causes are [of clinician burden], and then we’ll send a report to Congress, as required [by Cures]. Right now, documentation guidelines seem to be the most problematic piece of that, and that’s called out in the Cures Act.
This week, Alex Azar had really interesting comments about how value will be determined by the many players in the healthcare marketplace. But then Azar said, “This will require some degree of federal intervention—perhaps even an uncomfortable degree. That may sound surprising coming from an administration that deeply believes in the power of markets and competition.” That sounds like conflicting ideologies to me. Can you explain how this all might play out?
The ACA [Affordable Care Act] debate is really a debate about role of government in healthcare. The Trump administration and the HHS Secretary [Alex Azar] are all about re-engaging the consumer in healthcare.
As a society, we are trying to find our way. The federal and state governments definitely have a place in healthcare, but what is the sweet spot where we unleash innovation and let the private sector solve a lot of our problems? However, sometimes the private sector is unwilling to tackle those problems if they think they will run unto a highly-regulated environment in which they can’t build the efficiencies or the business models that make sense.
The major point you hear at HIMSS is the liquidity of the data—getting that information into the hands of that patient where the patient can shop for care and once again make it a marketplace. But it doesn’t end there; other things have to be done to return the efficiencies of marketplace back to healthcare. The transparency of data is absolutely a beginning point, though.
Going back to reducing clinician burden, in what specific ways can this goal come to fruition, and have you already started to see progress in this area?
We’re in the first stage of figuring out where these issues are coming from. We have had several stakeholder meetings, including three major listening sessions, and we actually have polled people in audience [of those sessions], so that we get an idea on clinicians’ pain points and their priorities. What is the most problematic of all the things causing burdens? We are collating data and will meet on that, but ultimately, we need to use that data and make recommendations to improve.
Providers point to the EHR system itself and they think that is the headache of their professional life. But it’s not just the EHRs themselves, but rather the stacks upon stacks of the requirements from regulations and mandates over the years that must be processed—and the systems aren’t capable of doing those things alone.
Regarding documentation, CMS has very prescriptive and strict guidelines for how much data you put about how many systems, and that’s the level of pay you receive. So naturally, a provider who wants to be paid fairly feels it’s a necessity to fill as many blanks and click as many boxes as possible. Even if that wasn’t a burden, the other side is [a burden] because you now end up with this huge document with normal findings, and hidden within that are a few gems of important information. So, the provider on the other end is reluctant to scan through all of it. The quality of the document is going down as the data is being put into it—most of the data is the description of just normal things.
You said something this morning about how historically, patients have “blindly” trusted their doctors—to the point where they’re not asking questions about medications being given to them, etc. And you said that as a physician, that made you uncomfortable. Can you expand on this thought?
The reason why I was uncomfortable with that was that I was worried I would disappoint a patient and if I didn’t come up with the instant solution to the problem, I would let that person down. Maybe I made a mistake as a human and didn’t have the right answer. It occurred to me that I can be a much more important factor in patients’ lives by educating them about their disease process and making them more literate in healthcare knowledge. And if I do that, now I have a partner by my side—and we succeed and fail together.
With the ability to put the health record in the hands of the patient, that’s another added dimension where we could have success. We are really into the medical-home approach where you might have nurses and other allied health [professionals] involved, and in many cases, they’re going into the patients’ homes to [intervene]. I have never found a person, even with limited education but normal intelligence, who couldn’t fully grasp any medical idea or concept without proper explanation.
Do you think the medical community agrees with what you just said?
There is an understandable fear. What if the patient discovers information, either incorrectly or prematurely? We have to try to take safeguards to try to be sure that we see the information first and we don’t let patients get ahead of us, but we should be timely with providing it to patients.