Healthcare groups urge ONC to focus on interoperability, usability to reduce EHR burdens

Healthcare and health IT industry groups are urging the Office of the National Coordinator for Health IT (ONC) to put a greater focus on usability and creating a better alignment of workflow and documentation requirements in their responses to a federal draft strategy on reducing the regulatory burden on clinicians caused by technology.

EHR burdens have been a near-constant complaint from physicians that see the technology as an impediment to their relationship with patients. Numerous studies have documented that EHR tasks take up a large part of a doctor’s workday.

In late November, the Department of Health and Human Services (HHS) issued its 74-page draft strategy, which was developed by ONC in partnership with the Centers for Medicare & Medicaid Services (CMS). The strategy, required under the 21st Century Cures Act, details three overarching goals to reduce clinician burden revolving around entering information into EHRs, meeting regulatory requirements and improving EHR ease of use.

Industry groups also encouraged HHS to look at leveraging newer technologies, such as artificial intelligence (AI), to reduce clinician burden around documenting in the EHR and meeting regulatory reporting requirements.

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Other written comments to the ONC included: 

  • A recommendation from the American Medical Informatics Association (AMIA) that the final HHS-wide strategy focus on a long-term goal of decoupling clinical documentation from billing, regulatory and administrative compliance requirements. “We have a 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,” AMIA wrote.

The organization noted that natural language processing, remote sensing, video capture and data mining are improving, yet these improvements only impact administrative burdens of EHRs at the margins. AMIA also stated that the core challenge and dominant threat to the HHS strategy is 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.” Documentation challenges go far beyond patient visits and Evaluation and Management (E/M) documentation guidelines, AMIA wrote, as the design of EHRs can be traced to regulations and programs such as Medicare Conditions of Participation, the Medicare Claims Processing Manual and the Office of Inspector General Workplan.

  • Comments from the Electronic Health Record Association (EHRA), a group that represents most major EHR vendors, noting that a “key contributor to the frustration of providers with EHR documentation requirements has been compliance with outdated guidelines which are geared to billing and policy requirements rather than patient care.” The association said it strongly supports policy directions which use information already present and relevant in the patient’s medical record to reduce redocumentation in the clinical note. HHS’ proposed strategy and CMS’ “Patients over Paperwork” initiatives are welcome steps toward more focused documentation requirements, EHRA said.
  • The American Hospital Association (AHA) agrees with HHS’ focus on reducing the overall E/M documentation burden; however, the association urges ONC and CMS to explore changes that go beyond high-level changes to E/M documentation, as well as documentation requirements applicable to other types of care, including care delivered via telehealth. AHA also called for HHS to evaluate whether certain documentation requirements should be eliminated rather than just modified. “ONC could work with EHR vendors to evaluate the extent to which providers actually access and use existing required documentation for clinical care after entry into the record, as a guide to determine what might be extraneous,” AHA wrote.

Several groups cited forthcoming regulations for EHRs to include application programming interfaces (APIs), as mandated by the Cures Act, as a critical step to reduce clinician burden. In its written comments, Pew Charitable Trusts said ONC should ensure that APIs support clinicians’ access to individual data elements without having to receive the entire patient record. Pew also noted that use of the FHIR standard will enable clinicians to extract only the information they need. “As a result, these APIs can reduce clinicians burden when using EHRs, but only if the interfaces are effectively implemented,” Pew wrote.

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To improve documentation and workflow, HIMSS and the Association of Medical Directors of Information Systems (AMDIS), in joint comments sent to ONC, recommended creation of a minimum data set that payers, including CMS, would use to identify services delivered during a patient visit and confirm payment decisions. “In the longer term, HIMSS and AMDIS encourage HHS to think more broadly about how to shift the paradigm from requiring clinicians to submit documentation to payers for coverage and reimbursement decisions to a scenario where health IT tools and approved devices send the structured data elements that payers need to make these decisions directly from an EHR.”

Many organizations support HHS’ proposal of leveraging health IT to improve the prior authorization process, which is often labor-intensive. The American Health Information Management Association noted that technologies are available, including AI-assisted products, that can streamline and automate the prior authorization process: “Where appropriate, we recommend that HHS seek to highlight such innovative approaches as part of its development and dissemination of best practices around prior authorization.”