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AMIA Calls for Strictly Clinical Documentation in Patient EHRs

The association is calling on HHS to separate billing, regulatory, and administrative compliance from clinical documentation in EHR design.

EHR clinical documentation

Source: Thinkstock

By Kyle Murphy, PhD

- The American Medical Informatics Association (AMIA) has offered a solution to regulatory and administrative burden — separate the clinical from the financial in EHR documentation.

In response to an ONC draft strategy for reducing EHR- and health IT-related regulatory and administrative burden, the association emphasized the need for EHR clinical documentation to support patient-centered care rather than remain a tool for satisfying requirements not tied to outcomes.

“Given the adoption trajectory and the ongoing evolution in the design of EHRs, we recommend this final HHS-wide Strategy be oriented towards a long-term goal of decoupling clinical documentation from billing, regulatory, and administrative compliance requirements,” wrote AMIA President & CEO Doug Fridsma, MD, PhD.

According to AMIA, a strict focus on the clinical value of EHR documentation will enable the creation of highly actionable data capable of improving the practice of medicine and the patient’s experience of care.

“We have a tremendous opportunity to leverage informatics tools and methodologies to decouple clinical documentation from billing and better integrate regulatory compliance requirements so that clinical decision support (CDS) and quality/performance reporting are better positioned to improve care for patients and reduce burden for clinicians,” Fridsma added.

Providers have long bemoaned the role that EHR documentation plays in reimbursement. The drawn-out transition to ICD-10 is a recent example of the clinical (i.e., “clinical observation and treatment”) butting heads with the regulatory and administrative (i.e., “billing requirements and business processes”) with the patient’s health record.

“Administrative and regulatory burdens have expanded steadily over more than 30 years,” stated Fridsma. “As we transitioned from paper records to digital data, we did not reevaluate these paradigms. The implementation of health IT simply replicated our paper processes and has magnified and modified pre-existing burdens and challenges.”

The AMIA letter specifically draws attention to the negative effect fee-for-service has had on EHR design.

“The design of EHRs — and the workflows such EHR designs compel — can be traced to a multiplicity of regulations and programs that are both deep-seated and arcane,” noted Fridsma.

As an example, the association’s head criticized Medicare Conditions of Participation creating a need for a host of functional requirements that fail to support providers at the point of care in any meaningful way.

“These and other HHS programs do not depend on data that reflects the patient’s clinical story. Instead, these programs compel different workflows designed to collect relevant data elements for specific functions like clinical decision support, performance measurement, and quality reporting,” Fridsma argued.

While regulatory and administrative compliance plays an important role in healthcare as a whole, they have a history of adding “enormous complexity” at the point of care. AMIA has called for more public-private collaboration to address documentation challenges and solutions.

“Health informatics, health information management, and health IT professionals need to be engaged in the design, development, and implementation of CMS requirements as well as the workflows those requirements compel,” wrote Fridsma. “Otherwise, front-line clinicians become over-burdened and are forced to rely on poorly designed and inefficient EHRs.”

In other words, the industry is putting reporting ahead of care. A solution requires a reimagining of healthcare within the context of outcomes rather than services. Data reporting has its place — it is a byproduct of the provider-patient encounter.

“If we are prepared to migrate from our paper-based paradigm where clinicians are expected to check boxes and move into a digital paradigm where clinicians are free to treat patients (and are not subject to being ‘trained’ how to document by billing experts), then we can markedly reduce clinical burden,” Fridsma maintained.

Going forward, AMIA asked HHS to reform E/M documentation guidelines, if not abandon them entirely. The federal agency should also work with specialists to develop appropriate documentation guidelines that will benefit both providers and researchers (e.g., informatics, IT development). Additionally, federal agencies need funding to research and develop solutions to documentation-related burden. Lastly, the association called on federal agencies to recognize the expense of data reporting and potentially compensate the latter appropriately for their time and resources.

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