Be a part of the solution: Comment on a draft strategy for reducing regulatory administrative burdens.
Do the practitioners in your organization complain about the administrative burden associated with the use of electronic health records (EHR) and other health information technology (IT)? You may be sick of hearing it, but the Office of the National Coordinator for Health Information Technology (ONC) isn’t. The federal office has been assessing feedback collected through several listening sessions, written input, and stakeholder outreach on that very subject, and has developed what they believe may be solutions toward correcting a common complaint: EHR documentation requirements take practitioners’ time and focus away from patients.
There are several federal programs that provide incentives for the adoption and meaningful use of EHRs (and disincentives for not using them), including the Medicare and Medicaid Promoting Interoperability Programs, the Merit-based Incentive Payment System (MIPS) and alternative payment models (APMs); and the Hospital Value-based Purchasing program. These initiatives have resulted in rapid adoption of EHRs. Unfortunately, neither EHRs nor clinicians were prepared.
In a press release, National Coordinator for Health Information Technology Don Rucker, MD, is quoted saying, “Information technology has automated processes in every industry except health care, where the introduction of EHRs resulted in additional burden on clinicians. Health IT tools need to be intuitive and functional so that clinicians can focus on their patients and not documentation. This draft strategy identifies ways the government and private sector can alleviate burden. I look forward to input from the public to improve this strategy.”
Stakeholders have until Jan. 28, 2019, to comment on the draft Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Heath IT and EHRs.
Strategizing a Solution
The ONC’s draft strategy outlines three overarching goals designed to reduce clinician burden:
- Reduce the time and effort it takes clinicians to document health information in EHRs;
- Reduce the time and effort required by clinicians and clinician groups to meet regulatory reporting requirements;
- Improve the ease of use of EHRs.
For each goal, the ONC has drafted recommendations for four strategies that pertain to clinical documentation, health IT usability and the user experience, EHR reporting, and public health reporting. Following is an outline of the recommendations under each strategy. Please read the full draft report for complete details.
Clinical Documentation
Strategy 1: Reduce regulatory burden around documentation requirements for patient visits.
Recommendation 1: Continue to reduce overall regulatory burden around documentation of patient encounters.
The Centers for Medicare & Medicaid Services (CMS) recently finalized provisions to change documentation requirements (and payments) for office and outpatient evaluation and management (E/M) services. “Efforts to reduce the overall burden associated with E/M documentation guidelines are likely to reduce EHR-related burden too,” the ONC states in the draft strategy.
Recommendation 2: Leverage data already present in the EHR to reduce re-documentation in the clinical note.
Starting in 2019, practitioners will no longer need to re-document certain history and exam data already present in the medical record during an office or outpatient E/M visit. CMS will allow the billing practitioner to simply review, update (where appropriate), and sign off on the data, as per the 2019 Medicare Physician Fee Schedule final rule.
Recommendation 3: Obtain ongoing stakeholder input about updates to documentation requirements.
The ONC encourages the U.S. Department of Health and Human Services (HHS) to continue soliciting for wide stakeholder input from key participants, including healthcare providers and payers.
Recommendation 4: Waive documentation requirements as may be necessary for purposed of testing or administering APMs.
CMS recently piloted a program to reduce medical review burden for certain APM participants. The ONC recommends CMS explore further use of this concept by waiving certain documentation requirements in APMs.
Strategy 2: Continue to partner with clinical stakeholders to encourage adoption of best practices related to documentation requirements.
Recommendation 1: Partner with clinical stakeholders to promote clinical documentation best practices.
Recommendation 2: Advance best practices for reducing documentation burden through learning curricula included in CMS Technical Assistance and models.
CMS already has technical assistance solutions in place, such as the Transforming Clinical Practice Initiative, MACRA Technical Assistance, Innovation Center model learning and diffusion activities, and Quality Improvement Organizations. The ONC recommends CMS publicize these initiatives.
Strategy 3: Leverage health IT to standardize data and processes around ordering services and related prior authorization processes.
Recommendation 1: Evaluate and address other process and clinical workflow factors contributing to burden associated with prior authorization.
Recommendation 2: Support automation of ordering and prior authorization processes for medical services and equipment through adoption of standardized templates, data elements, and real-time standards-based electronic transactions between providers, suppliers, and payers.
Recommendation 3: Incentivize adoption of technology which can generate and exchange standardized data supporting documentation needs for ordering and prior authorization processes.
Recommendation 4: Work with payers and other intermediary entities to support pilots for standardized electronic ordering of services.
Recommendation 5: Coordinate efforts to advance new standard approaches supporting prior authorization.
Health IT Usability and the User Experience
Strategy 1: Improve usability through better alignment of EHRs with clinical workflow; improve decision making and documentation tools.
Recommendation 1: Better align EHR system design with real-world clinical workflow.
Recommendation 2: Improve clinical decision support usability.
Recommendation 3: Improve clinical documentation functionality.
Recommendation 4: Improve presentation of clinical data within EHRs.
Strategy 2: Promote user interface optimization in health IT that will improve the efficiency, experience, and end user satisfaction.
Recommendation 1: Harmonize user actions for basic clinical operations across EHRs.
Recommendation 1: Increase end user engagement and training.
Recommendation 2: Promote and improve user interface design standards specific to health care delivery.
Recommendation 3: Improve internal consistency within health IT products.
Recommendation 4: Promote proper integration of the physical environment with EHR use.
Strategy 3: Promote harmonization surrounding clinical content contained in health IT to reduce burden.
Recommendation 1: Standardize medication information within health IT.
Recommendation 2: Standardize order entry content within health IT.
Recommendation 3: Standardize results display conventions within health IT.
Strategy 4: Improve health IT usability by promoting the importance of implementation decisions for clinician efficiency, satisfaction, and lowered burden.
Recommendation 1: Increase end user engagement and training.
Recommendation 2: Promote understanding of budget requirements for success.
Recommendation 3: Optimize system log-on for end users to reduce burden.
Recommendation 4: Continue to promote nationwide strategies that further the exchange of electronic health information to improve interoperability, usability, and reduce burden.
EHR Reporting
Strategy 1: Address program reporting and participation burdens by simplifying program requirements and incentivizing new approaches that are both easier and provide better value to clinicians.
Recommendation 1: Simplify the scoring model for the Promoting Interoperability performance category.
In the 2019 rulemaking cycle, CMS finalized the restructure of program requirements for both the Promoting Interoperability performance category in MIPS and the Medicare Promoting Interoperability Program for eligible hospitals and critical access hospitals. The restructure included a significant overhaul of the scoring methodology for both programs and introduced new measures.
Recommendation 2: Incentivize innovative uses of health IT and interoperability that reduce reporting burdens and provide greater value to physicians.
Recommendation 3: Reduce burden of health IT measurement by continuing to improve current health IT measures and developing new health IT measures that focus on interoperability, relevance of measure to clinical practice and patient improvement, and electronic data collection that aligns with clinical workflow.
Recommendation 4: To the extent permitted by law, continue to provide states with federal Medicaid funding for health IT systems and to promote interoperability among Medicaid health care providers.
Recommendation 5: Revise program feedback reports to better support clinician needs and improve care.
Strategy 2: Leverage health IT functionality to reduce administrative and financial burdens associated with quality and EHR reporting programs.
Recommendation 1: Recognize industry-approved best practices for data mapping to improve data accuracy and reduce administrative and financial burdens associated with health IT reporting.
Recommendation 2: Adopt additional data standards to makes access to data, extraction of data from health IT systems, integration of data across multiple health IT systems, and analysis of data easier and less costly for physicians and hospitals.
Recommendation 3: Implement an open API approach to HHS electronic administrative systems to promote integration with existing health IT products.
Strategy 3: Improving the value and usability of electronic clinical quality measures while decreasing health care provider burden
Recommendation 1: Consider the feasibility of adopting a first-year test reporting approach for newly developed electronic clinical quality measures.
Recommendation 2: Continue to evaluate the current landscape and future directions of electronic quality measurement and provide a roadmap toward increased electronic reporting through the eCQM Strategy Project.
Recommendation 3: Explore alternate, less burdensome approaches to electronic quality measurement through pilot programs and reporting program incentives.
Public Health Reporting
Strategy 1: Increase adoption of electronic prescribing of controlled substances and retrieval of medication history from state PDMP through improved integration of health IT into health care provider workflow.
Recommendation 1: Federal agencies, in partnership with states, should improve interoperability between health IT and PDMPs through the adoption of common industry standards consistent with ONC and CMS policies and the HIPAA Privacy and Security Rules, to improve timely access to medication histories in PDMPs. States should also leverage funding sources, including but not limited to 100 percent federal Medicaid financing under the SUPPORT for Patients and Communities Act, to facilitate EHR integration with PDMPs using existing standards.
Recommendation 2: HHS should increase adoption of electronic prescribing of controlled substances with access to medication history to better inform appropriate prescribing of controlled substances.
Strategy 2: Inventory reporting requirements for federal health care and public health programs that rely on EHR data to reduce collection and reporting burden on clinicians. Focus on harmonizing requirements across federally funded programs that impact a critical mass of health care providers.
Recommendation 1: HHS should convene key stakeholders, including state public health departments and community health centers, to inventory reporting requirements from federally funded public health programs that rely on EHR data. Based on that inventory, relevant federal agencies should work together to identify common data reported to relevant state health departments and federal program-specific reporting platforms.
Recommendation 2: HHS should continue to work to harmonize reporting requirements across federally funded programs requiring the same or similar EHR data from health care providers to streamline the reporting process across state and federal agencies using common standards.
Recommendation 3: HHS should provide guidance about HIPAA privacy requirements and federal confidentiality requirements governing substance use disorder health information in order to better facilitate electronic exchange of health information for patient care.