Making EHRs Doc-Friendly Only Part of the Job in the Feds' Health IT Office
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Monday, November 06, 2017 08:26 AM

John Fleming, MD, is the deputy assistant secretary for health technology reform at the Office of the National Coordinator (ONC) for Health Information Technology, notes that “there has been layer on layer on layer of burden on physicians since the early 1980s, and computers increased it — one of the biggest burdens is documentation guidelines,” said Fleming. 

Fleming got interested in electronic health records (EHRs) early in his career. He opened up a private practice in Louisiana in 1982 and began dictating his notes for later transcription into a computer. “I was impressed with the productivity derived from computerization," said Fleming. "It became a very, very helpful tool." “I began to look around and say, 'Why don't we have this in healthcare?'" He purchased his first medical office computer system — an off-the-shelf product — in 1997, “and by 1999 we were fully paperless, and it improved our efficiency."  Unlike some physicians, Fleming had a good experience with his system.

In 2008 he was elected to Congress in Louisiana's 4th District and saw the trouble that was created for doctors using medical records when the Health Information Technology for Economic and Clinical Health (HITECH) was passed the following year; that law required physicians to demonstrate "meaningful use" of electronic health records.

“Some of the benefit I enjoyed early on [with my computer system] began to diminish as Meaningful Use came in," said Fleming. "Healthcare decision-making and data collection and tracking is far more complex than other industries. It also requires the provider to be a clerk.”  Because of the requirement, he said, “interface development has not gotten the attention it needs because [EHR developers] are working on Meaningful Use requirements," he said.

Fleming found that introducing EHRs to his peers was difficult “because I and my colleagues were really in the pre-computer days, so there was a lot of resistance there," he said. Part of the reason for that, he thinks, is that when most physicians installed their EHRs, they were dealing with two sets of records -- their paper system and their electronic system -- because they didn't fully trust the EHR. "So they were worse off. It's better to be with one or the other than both at the same time ... And [it was done] without the full commitment of providers. They would do it very grudgingly. Most practice grafted their new system onto their current workflow,” Fleming explained.

After four terms in Congress, Fleming ran unsuccessfully for a Senate seat and was then appointed to his current position based on his interest in healthcare computing. He sees his job as helping physicians get out from under some of the burdens that government regulations have created.

The evolution of the current Medicare payment system began around 1984, when Medicare froze the prices it would pay physicians; that evolved into a mathematical calculation "reasonable and customary" fees, which in turn became the Resource-Based Relative Value Scale (RBRVS), which still exists today, Fleming said.

"Then, in about 1995, Congress decided doctors would be paid more or less depending on the amount of work they did for a patient in a given encounter. So they came up with documentation guidelines, which said that based on amount of history, the amount and complexity of physical exam, and the amount of decision-making, you can charge at different levels, and get paid more for a complex patient."

The EHR developers then decided they could help with that by putting in "stock language" for some of these elements -- for example, a whole page of text that outlined a normal review of systems. “It was an early attempt to make it more efficient for the doctor to put the data in there. But the unintended consequence of that was that progress notes [now included] 3-4 pages of 'normal' statements which camouflage the actual information that doctors are looking for," said Fleming. “So technology made it more difficult to interpret the data, and we're struggling with that today."

All these changes had a huge impact on productivity, he continued. For example, “the percentage of physicians employed by hospitals has gone from 25% to 75% in the last 8-10 years, because they just can't make a living" as independent providers. "That's why many doctors view the EHR as a manifestation of their burdens."

“I'd estimate that before the advent of the EHR, I would spend about 10% of their time writing or dictating [progress] notes," he said. "Time/motion studies show it's now 50% to 75% of the time. It's a huge loss of productivity." If that could be fixed, "think of the productivity that could be unleashed across the country. That would mean more patient time, more face-to-face time, and [an increase] in the number of patients."

The recently passed 21st Century Cures Act had two provisions related to physician practices: the first was aimed at improving EHR interoperability, in part by restricting EHR vendors and others from blocking the flow of information from one office or health system to another. The second was providing relief for regulatory burdens on physicians.

“One area that CMS has gotten a lot of input on is revising those documentation guidelines from 1995 and 1997, to relieve that burden so doctors don't feel they have to drop a lot of text into progress notes that do nothing but camouflage real information," said Fleming. “I think that would be a huge relief."