Curbside Consult with Dr. Jayne 2/12/18

I was heartened this week to see the American Academy of Family Physicians engaging with ONC in an attempt to “reduce clinician burden from health information technology.” AAFP has been meeting with CMS and ONC as part of the Patients over Paperwork initiative, and submitted what amounts to a wish list of items to discuss at a follow-up meeting later this month.

The letter opens with commentary about the regulations that physicians are subject to are “daunting and often demoralizing.” AAFP cites lack of standardization among payers, whether public or private, as a significant challenge.

The letter cites family physicians as possibility participating with 10 or more payers, which is a significantly smaller number than what we see in our community. In my family medicine heyday, I was contracted with nearly 35 payers, including Medicare and Medicaid for two states. Just the credentialing paperwork alone was mind-numbing, and the actual paperwork that needed completion to actually care for patients was soul-crushing. Every plan had a different pre-authorization form, certification process, and appeals framework. Although I was part of a large health system, my personal office staff spent a significant amount of time dealing with it since we had no centralized resources to assist.

AAFP refers to their wish list as “consensus principles on administrative simplification” and many of them seem like common sense measures. First, they call for CMS and ONC to work with Congress to reduce the reliance on healthcare IT usage measures. Their point is that programs such as MIPS are already measuring quality, cost, and practice improvement, so measuring the usage of IT systems is no longer necessary. AAFP calls for policies that mandate health IT use to be assessed to identify “evidence of benefit and burden in real-world practice prior to their implementation.”

I agree with this request wholeheartedly. Many of the requirements found in these programs seemed like a good idea to the people who designed them, but when they’re placed into practice, they fall flat. An example is the requirement that physicians send certain percentages of prescriptions electronically, including controlled substances. There was no corresponding requirement to mandate that pharmacies update their systems, resulting in delays for physicians who wanted to use the technology and frustration for those whose service areas didn’t have adequate pharmacy adoption. Requiring certain numbers to be met also doesn’t take into account the preference of certain patient populations who want a hard copy of the prescription to take with them.

Many of my older patients didn’t trust electronic prescribing or had experienced delays or misadventures with it previously, and simply wanted paper prescriptions. Even if I tried to e-prescribe and then print a backup copy for the patient, the way our EHR calculated the transactions, I would still be on the hook for a printed prescription. Meeting my patients’ needs and preferences for care put me at risk for a penalty, which just seems wrong.

One of the more hot-button requests in the AAFP letter is a request that the CMS Documentation Guidelines for Evaluation and Management Services (E&M Coding) be overhauled. It notes that, “adherence to E/M Documentation Guidelines consumes a significant amount of physician time and does not reflect the workflow of primary care physicians.” They cite the creation of the Guidelines for the paper world as being part of the problem, and that the Guidelines don’t take into account how EHRs support care and documentation.

They go as far as asking that guidelines for new and established office visits be eliminated for primary care physicians. That’s certainly a big ask and personally I don’t see it happening, but I’m glad they’re trying. I’d love to see the guidelines at least modified to allow for different types of documentation to “count” for coding points. For example, when my patients come in with rashes, I’d love to be able to drop in a couple of pictures of the rashes and call it a day rather than trying to find the right checkboxes to click to try to describe a rash in a way that may not convey what I saw. Under the current requirements, I can drop that photo in, but I still have to use words in order to get billing credit.

My favorite request in their list is a request that the Medicare Program Integrity Manual be updated “to allow medical information to be entered by any care team member related to a patient’s visit” and that it be changed across the board for all Medicare contractors, Medicaid programs, and private payers. We’ve been living in a world with arbitrary boundaries where staff can document the Review of Systems but not capture any History of Present Illness (HPI) data, even if the patient volunteers it. Of course, this is if your employer follows a strict interpretation of the rules, which many do. Other practices may allow staff to collect HPI data and have the rendering provider review it, which saves time and effort, but I see that less commonly.

The original E&M guidelines also don’t fully address the requirements of patient documentation when scribes are used, and whether documentation can be performed differently depending on the training and education of the scribe. For instance, if I have a registered nurse scribing for me, I may get more detailed documentation than if I have a less-trained scribe, because the nurse may pick up more specifics from my descriptions. A patient care technician might enter my statements verbatim (I often speak in lay terms to patients when I explain their exam findings) where a nurse may translate these descriptions to accepted medical terminology.

AAFP also calls on CMS and ONC to go after those who are guilty of information blocking. Administrators, listen up: when you’re ready to go after some major health systems, give me a call. They’re the biggest offenders in my metropolitan area and the EHR vendors don’t have anything to do with it. It’s all about controlling your referrals and managing your ACO and not about enabling patient choice or sharing of clinical data. Too bad there’s not a whistleblower clause since  maybe I could retire early.

The letter evokes the myth of interoperability, where many of us are exchanging reams of irrelevant information that we don’t have time to wade through. Even though I haven’t been a family physician for years, I still appear in many patients’ records and receive C-CDA documents on a frequent basis. Most of them are unintelligible, and one local hospital is guilty of including every medication the patient has ever been on, which I imagine makes medication reconciliation nearly impossible for the receiving party.

The letter notes the need for consistent data models created by clinicians rather than by legislators or software engineers. I deal with several EHR vendors that don’t even really have a data model of their own, which is amazing to me in this post-Meaningful Use age. When data comes in from another vendor, it creates a mess that is hard to sort out and adds considerable junk to the patient chart. It also notes the need to continue to harmonize clinical measures, so that physicians don’t have to report data that is similar but not identical to different payers.

Other factors mentioned should be no-brainers in this day and age, such as removing the need for physicians to fill out new forms for items like diabetic supplies when a patient switches brands. Especially if we are trying to allow patients to be empowered and make choices about cost of drugs and supplies, having to write for “WonderGlucose Harmonious Precision Extra” as opposed to “glucometer test strips” is silly.

The letter closes with a request for CMS and ONC to reach out to Steven Waldren, a family physician who is the Director of the Alliance for eHealth Innovation. I had a chance to meet Dr. Waldren a couple of years ago at HIMSS and he’s a knowledgeable physician with a good head on his shoulders. For some reason, however, I don’t suspect that his phone is ringing off the hook with regulators asking how they can help. I’m interested to see if other specialty organizations follow suit and whether we see any changes.

What would you do with your free time,should E&M coding be eliminated? Email me.

Email Dr. Jayne.