Curbside Consult with Dr. Jayne 2/7/22

As a consulting clinical informaticist, one of the things I’m often tasked with is EHR optimization. Sometimes clients have robust structures for receiving feedback from clinical users as well as teams who are tasked with assessing workflows and recommending changes. In those situations, I might provide clinical input as they work through issues, getting proposed changes polished before we take them out to stakeholders for feedback. That’s a lot of fun, because the end users appreciate having a fully vetted solution presented to them versus having to be involved in the details of process.

Other times, clients need someone to help them create a structure to handle feedback and recommend solutions. Those projects are also rewarding because users really like feeling like they’re being heard and that someone cares, even if the process you’re creating is just getting started.

One of the hot topics in optimization right now is figuring out how to lighten physician documentation requirements. It’s been a year since the Centers for Medicare & Medicaid Services modified the Evaluation & Management coding requirements with the goal of simplifying documentation. Many clinicians thought the changes were too good to be true and I don’t blame them. Coming from a large health system background, I felt that the years of internal compliance audits had created a certain level of fear around under-documenting or over-coding. We had been conditioned to make sure we were documenting more than enough Review of Systems and Physical Exam checkboxes just to be on the safe side. This was made more complex when one needed to document an element that could be counted in two different systems, and most of the physicians I know had come to dread any conversation around coding.

Now that there has been some flexibility, and people have learned that auditors aren’t waiting around every corner to catch someone who isn’t documenting correctly, physicians are eagerly pushing their organizations to remove the excessive clicking that physicians and their support staff members have been complaining about for years. As people have reassessed their priorities during the pandemic, clinical users have been increasingly vocal about how much they feel technology is contributing to burnout. With staffing levels as dire as they are in some organizations, those organizations have figured out that they can’t afford to not listen to what their employees are saying. Those organizations who have consciously looked at how their users work have also figured out that so-called “note bloat” makes it harder to care for patients since notes that contain extraneous information make it harder to find the data elements that are important.

Physicians and other users who had created extensive macros to satisfy the previous E&M requirements are now spending time trimming down the content of those macros to better reflect what they do in a typical patient visit. Adjusting those configurations takes time, and end-users are eager to have an analyst or super user make the changes whenever possible. Depending on the EHR, the effort needed to do this can range from straightforward to cumbersome. Not surprisingly, I see more progress on “easy” systems than I do on those that require greater involvement of IT or other teams. Sometimes the level of difficulty to make a change is murky, though. The fact that I’ve worked in so many different EHRs is certainly an advantage when analysts push back and try to make it seem like it’s more complicated to make a change than it really is.

I also see more physicians who are using time-based coding since figuring out how to document that has become a bit easier. In the past, you had to keep track of how much of the visit was face-to-face, how much was counseling and coordination of care, etc. Now the majority of elements performed by a provider on the day of service count, making it much more likely that a physician might choose to code based on the duration of effort. This has led to greater number of high-level visits being coded by physician. Although one would think this should lead to greater pay for physicians, I’ve seen a number of organizations figure out ways to avoid paying their clinicians more. Some have made adjustments to keep physician salaries relatively flat, keeping a greater portion of the payments for the organization versus passing them on to the people doing the work.

When I hear that the latter is happening, I try to push optimization as much as possible in order to ensure the end users feel some relief. Even if they’re not receiving better compensation, I can hopefully make their days at least a little bit shorter and their visits a little easier.

There have been a couple of times recently when I’ve felt really torn when working on an optimization project. I’ve gotten a sense that administrators will perceive that the physicians are doing less work, will translate this to a perception that the physicians have greater capacity, and then continue to shift work towards them. We saw a great shift of low-level clinical work to physicians at the beginning of the Meaningful Use program, and physicians had to fight hard to get organizations to agree that they needed their support staff to take on some of this work. The idea of working at the top of your license could be used to show that physicians were expensive, and if you had more staff, you could see more patients and those changes were revenue neutral or even positive.

Now that there is such a labor shortage, finding capable staff at a price organizations and administrators are willing to pay can be tricky. Not surprisingly, physicians have filled the gap because it’s the right thing to do for their patients, but it’s hard to convince decision makers to look for unicorn-like staff members in this market when they know the physicians will do the work for free. No amount of optimization is going to improve clinician morale if they feel like they’re being pulled into a black hole of ongoing work with no help in sight. I’m interested in understanding how large organizations have optimized their systems based on the changes to the Evaluation & Management codes.

Are your ambulatory physicians writing the shortest notes of their careers with the same billing codes? Leave a comment or email me.

Email Dr. Jayne.