In comments submitted on Monday to the Office of the National Coordinator for Health Information Technology (ONC) and the Center for Medicare & Medicaid Services (CMS), the American Medical Informatics Association (AMIA) recommended that the Department of Health and Human Services (HHS) orient its documentation burden reduction strategy towards a long-term goal of decoupling clinical documentation from billing, regulatory, and administrative compliance requirements.
In late November 2018, ONC and CMS released its draft “Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Health IT and EHRs.” The strategy, which is required by the 21st Century Cures Act, outlines three overarching goals that aim to reduce clinician burden: reduce the effort and time required to record health information in EHRs for clinicians; reduce the effort and time required to meet regulatory reporting requirements for clinicians, hospitals, and healthcare organizations; and improve the functionality and intuitiveness of EHRs.
The draft strategy laid out four focus areas – including clinical documentation, health IT usability and user experience, EHR reporting, and public health reporting – setting forth dozens of recommendations to reduce administrative and regulatory burden.
In response, AMIA “strongly supported” the HHS strategy and the organization highlighted the “tremendous opportunity to leverage informatics tools and methodologies to decouple clinical documentation from billing and better integrate regulatory compliance requirements so that clinical decision support (CDS) and quality/performance reporting are better positioned to improve care for patients and reduce burden for clinicians.” However, the group warned that “the core challenge and dominant threat to [the HHS] Strategy are that most EHRs are designed to support transaction-based, fee-for-service (FFS) billing requirements and business processes for regulatory/administrative compliance, rather than reflect clinical observation and treatment.”
The group noted that while the Promoting Interoperability Program and Merit-based Incentive Payment System (MIPS) are prominent examples of regulations impacting the use of health IT and clinical workflows, there are many other programs and policies that create burden related to the use of health IT and EHRs. For example, Medicare Conditions of Participation, the Medicare Claims Processing Manual, and the Office of Inspector General Work Plan each compel EHR workflow design for their own purposes that increase provider burden.
In commenting on clinical documentation, AMIA recommended that both HHS and regulated industry (developers, providers, and payers) must agree to decouple clinical documentation from billing, administrative, and regulatory requirements with the expectation that documentation is used downstream for clinical decision support and quality/performance reporting as a byproduct of care delivery.
AMIA emphasized the achievable goal of decoupling clinical documentation from billing, regulatory, and administrative compliance requirements by creating an authoritative body from professional and specialty societies to:
(1) assess clinical documentation requirements
(2) evaluate technological capabilities available today to extract then report data
(3) define a financial mechanism to remunerate clinicians, hospitals, and healthcare systems for their work
“AMIA and the informatics community have a rich history of innovation, implementation, and evaluation of IT-enabled documentation,” said AMIA President and CEO Douglas B. Fridsma, MD, Ph.D., FACP, FACMI. “Rather than be the focal point of a clinical visit, technology should be invisible to our clinicians’ workflows. Our regulatory and policy approaches need a paradigm shift so that our informatics tools can realize their potential to heal healthcare.”
AMIA also called on ONC, the National Library of Medicine, and the Agency for Healthcare Research and Quality to dedicate funding to documentation-related R&D. Relatedly, AMIA reiterated its recommendation that these agencies should work together to develop a generalizable metric that captures the cost of data collection and identifies ways to leverage this metric across programs that require a deliberate collection of data outside routine care delivery.
In response to the health IT usability and the user experience section of the strategy, AMIA encouraged ONC to “leverage its Certification Program more explicitly and adopt a national universal set of standards for EHR symbols, shapes, and colors for ancillary service reporting and medication labeling nomenclature.” AMIA also urged ONC to encourage Certified EHR Technology developers’ usability and user experience data available to researchers “so that we can learn from tracking, trending, aggregating, investigating patterns of problems at the transaction unit of the patient encounter.”
Finally, AMIA applauded CMS and ONC efforts to identify program requirements that encourage clinicians to engage in higher-value health IT functionality and meet multiple programmatic requirements. However, it cautioned CMS against the inclination to reduce or eliminate public health reporting measures. Keeping such measures in place, AMIA argued, will help to enable convergence on a diversity of standards and requirements across federal, state, and local jurisdictions. AMIA instead encouraged CMS to “partner with other federal agencies, state and local agencies, and professional groups to develop ‘model’ reporting standards that would foster greater consistency in public health reporting.”
“As our healthcare system continues to evolve, new technologies will fundamentally alter how the patient’s story is captured, communicated, and understood,” said Dr. Fridsma. “We must ensure that our regulations and programs enable this transformation – not inhibit it.”
