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Appl Clin Inform 2018; 09(04): 914-918
DOI: 10.1055/s-0038-1676337
Invited Editorial
Georg Thieme Verlag KG Stuttgart · New York

CMS Payment Policy, E&M Guideline Reform, and the Prospect of Electronic Health Record Optimization

Peter Basch
1   MedStar Health, Washington, District of Columbia, United States
,
Jeffery R. L. Smith
2   American Medical Informatics Association, Bethesda, Maryland, United States
› Author Affiliations
Further Information

Publication History

28 August 2018

28 October 2018

Publication Date:
26 December 2018 (online)

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The potential for the widespread use of electronic health records (EHRs) to improve the quality and safety of health care was a key theme of the Institute of Medicine's seminal report of 2001, “Crossing the Quality Chasm.”[1] EHRs were envisioned as infrastructure to a better systems-level approach to health care delivery, leveraging information technology (IT) functionality, such as point-of-care order entry and clinical decision support. This groundbreaking report further anticipated two levers that would make the capabilities within EHRs more likely to be consistently used for the purposes of care improvement—payment policy and efficiency.

It was understood that clinician payment would need to move from just paying for procedures and services, to also paying for the enhanced use of health information to improve outcomes.[2] And it was assumed that operational efficiency, an intrinsic capability of mature IT seen in all other sectors, would also be seen in health care. The idea was that if physicians and other clinicians could be induced or incented to purchase and use EHRs, everyday time-consuming “paperwork” burdens would greatly diminish (or disappear!); and supported by payment policy, clinicians would make use of this new found time to focus on improving quality and safety, and perhaps even doing their part to make care more affordable.

Fast forward to 2018, and at least part of that vision is bearing fruit. While the evidence is mixed, there exists a reasonable argument for thoughtful use of EHRs resulting in better and safer care.[3] However, there is scant evidence that use of EHRs has made health care delivery more efficient; to the contrary—the pre-EHR complaint of “I spend more time on paperwork than I do with patients” has been replaced with an even louder cry of “I spend more time with my EHRs than I do with patients.”[4] In fact, physicians now perceive EHRs as the cause of—not a solution to—inefficiency, and the primary cause of physician burnout.[5] [6] [7]

What happened? Implementation of IT in fields other than health care have shown (after a period of training and workflow adjustment) efficiency gains for technology end-users.[8] Similar efficiency gains were assumed after the implementation of an EHR. However, persistent inefficiency in health care operations continues despite EHR implementation due to friction from two preexisting conditions: administrative or “paperwork” burdens—such as formulary adherence and prior authorizations—and the regulatory burden of documentation for payment purposes (the Evaluation and Management Documentation Guidelines [E&M Guidelines]). Two new areas of burden further exacerbate health care inefficiency, including regulatory burden associated with specific documentation for incentive and/or quality programs, and what can be called “EHR burden”—burden resulting from poor design and usability, suboptimal implementation, and inadequate training.

The proposed 2019 Medicare Physician Fee Schedule[9] (PFS) represents the first time the Trump administration has sought to imprint its deregulatory ethos toward Centers for Medicare and Medicaid Services (CMS) payment policy at scale; with leadership at the Department of Health and Human Services (HHS) signaling a continuation of value-based care and a refocusing on both quality “measures that matter,”[10] and the placing of “patients over paperwork,”[11] as top priorities. Key among proposed changes in the PFS is a streamlining of the existing E&M Guidelines.

This commentary will explore how a reduction in regulatory documentation burden, through E&M Guideline reform, could favorably impact clinicians' use and interaction with EHRs, and in turn, improve the doctor–patient relationship. This commentary will not address one of the more controversial components of this proposed rule—that of creating leveling payment for outpatient office visits.

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The authors certify that no human subjects were involved in development of this material.