According to CMS, the proposed rules “would fundamentally improve the nation’s healthcare system and help restore the doctor-patient relationship by empowering clinicians to use their electronic health records (EHRs) to document clinically meaningful information, instead of information that is only for billing purposes.”
When the news broke, physicians across the country jumped up and yelled, “Hallelujah!” – because what doctor hasn’t felt overburdened by all the excessive documentation requirements that were designed to facilitate billing but actually disrupt clinical workflows and the physician/patient interaction?
Of course, the devil is in the details – and we won’t have too many specific details until (and presumably if) CMS issues a final rule. However, I fear that despite all the hype, the new rules may create a whole new set of challenges that will add to physician frustration.
Bye-bye bullets but…
CMS is proposing simplified and streamlined documentation requirements for Evaluation and Management (E&M) office visits, including allowing practitioners to choose to document E&M visits using medical decision-making or time, instead of the current E&M documentation guidelines. This means physicians would be paid based on their medical decision-making and would no longer have to count “bullets” to justify a particular coding level – which is a welcome change.
However, how exactly will the government assess medical decision-making? For example, if a selected code indicates complex decision-making, what will CMS require in terms of documentation to support the higher code? The physician would likely have to provide sufficient details on the clinically significant factors that added to the complexity. Those elements might be stored in multiple sections of the chart and not necessarily be documented in the most current visit. Or, some critical details may actually be part of a clinical record from another healthcare provider.
To create documentation that justifies a higher-level code, the physician may need to exit the regular documentation workflow and import supporting information. In other words, we cannot and should not just assume that the elimination of bullet-counting will necessarily simplify and streamline the documentation process because physicians may be required to substantiate every aspect of the medical decision process.
Hello problems
The proposed rules may also force fundamental changes in how clinical information is presented in EHRs and in workflows. It could require a switch to a more problem-oriented patient record that provides a better view of the clinical relationship between a particular diagnosis and treatment.
While a problem-oriented medical record may be helpful when justifying billing codes, this style of record is sometimes criticized because of the potential difficulties managing the records of patients with multiple problems. For example, when inputting vital signs for a patient’s visit, an EHR may require the clinician to enter those same details multiple times – once for each of the problems being evaluated for the current visit. Another criticism of problem-oriented medical records is that problems are not always prioritized by severity but instead chronologically. While a chronical view may be efficient for billing, it’s not optimal for a clinician managing the health of a patient with multiple chronic conditions.
Promoting interoperability but…
CMS’s proposed changes to reduce documentation burdens are likely to promote EHR interoperability, though the government says “stay tuned” for more details. But it’s safe to assume that CMS will continue to pressure both vendors and providers to open up their systems and share clinical data – or risk financial penalties.
Interoperability remains a struggle in healthcare in part because vendors fear clinical data sharing makes it easier for clients to replace them with competing systems. Health systems also fear that by exchanging patient medical histories, they risk losing marketing share to a competing health system across town. An additional concern for some hospitals is that competing organizations will use shared records to extrapolate confidential details about patient volumes or the number of procedures performed.
However, if physicians are expected to justify complex medical decisions, they will demand ready access to their patients’ complete medical histories – and interoperability will be unavoidable, regardless of vendor and health system fears. CMS may have to escalate the use of carrot and sticks to drive interoperability, but it’s the only way physicians will have all the details required to make meaningful clinical decisions – and be appropriately reimbursed.
Yes, the devil is in the details, but my take is that reducing documentation burdens will be far from simple – and that without thoughtful planning, aligned incentives and the right technology, we could be trading the devil we know for the one unknown.
Jay Anders, MD is the Chief Medical Officer of Medicomp Systems. Dr. Anders supports product development, serving as a representative and voice for the physician and healthcare community. Dr. Anders spearheads Medicomp’s clinical advisory board, working closely with doctors and nurses to ensure that all Medicomp products are developed based on user needs and preferences to enhance usability.
