- With the entire healthcare industry undergoing tremendous amounts of change — from how care is coordinated and delivered to how providers are reimbursed for that care — there are likely to be side effects.
One the head of the American Medical Association (AMA) is targeting is the matter of physician burnout tied to providers having to balance the day-to-day realities of patient care with federal and state mandates regulating aspects of that care such physician EHR use and clinical quality reporting.
"Doctors will get behind things that support better quality of care and support them in their clinical practice. It's the nonsensical stuff that makes it infuriating and challenging," AMA President Steve Stack, MD, tells EHRIntelligence.com.
"When we are going to get adverse consequences to ourselves or hospitals by complying with the current thinking in medical treatment rather than outdated quality reporting and regulation," he continues, "those sorts of things are good examples where regulation is not a good tool at times to try to keep up with the fast pace of medical innovation, and good intentions can lead to undesired adverse consequences."
Stack points to recent evidence of physician burnout published last fall in Mayo Clinic Proceedings reporting a significant uptick in physicians reporting at least one sign of burnout over the past several years — from 45 percent in 2011 to 54 percent in 2014 — and what it means to a physician's practice of medicine.
"Now when physicians get burned out, they feel overworked, overburdened, overstressed, under-supported — just like anyone in any other profession, except that in this profession people rely on us to make very high-stakes decisions that directly impact their health and if we don't get it right, the consequences are not retrievable unfortunately at times," he maintains.
According to Stack, demonstrating meaningful EHR use as part of the EHR Incentive Programs serves as a perfect example of how regulation can contribute to physician burnout.*
NB. The recently issued propose rule for MACRA implementation will end meaningful use for physicians in 2017.
"Electronic health records have a great amount of promise," he explains. "Many doctors actually enjoy a lot of facets of their EHRs — the ready access to information, the ability to see historical information, the ability to share information with other doctors, other clinicians, and their patients directly so that patients can be more informed. Those are all good things, but there are many other aspects of the EHR that are frustrating. They are inefficient to use. They don't talk to each other. They cost a lot of money. When they crash or go down, it paralyzes our ability to do our work and care for patients."
Listen to the Xtelligent Media Podcast with AMA President Steve Stack, MD
As a result of those inefficiencies, physicians are forced to make up the difference.
"We now have physicians who on weekends and in evenings are spending time at home working on those computers instead of spending downtime with their kids and with their spouses," says Stack. "That downtime is important so that they are emotionally recharged so when they go deal with patients who are suffering or are facing catastrophe in their own lives, they have the emotional reserve and energy to be strong and supportive of the patient's needs."
As Stack makes clear, physicians are not adverse to new technology — in fact, they rely on emerging advancements in evidence-based medicine to provide the best care possible for their patients. What they have little patience for is new technology that falls short of keeping pace with their practice of medicine.
"We use incredible surgical tools to do things today that were science fiction 100 years ago for sure, 50 or 25 years ago for much of what we do," he emphasizes. "When we then turn to electronic health records and we explain that we are frustrated that the tools make us less efficient — that the mandates have turned us in to secretaries and clerks instead of efficient and high-performing physicians, when we say that the electronic health record takes us away and robs us of time to spend with our patients and that it's a frustration for the doctor and for the patient — we then get very consternated."
Through several physician town halls on the subject of meaningful use requirements and EHR use across the country, Stack has come away with the realization that physicians are not sufficiently represented at the table are far as EHR design and use are concerned.
"We think that in all the other technologies we use we demonstrate that we are voracious and rapid adopters of new technology when it works well for patients and for us," he claims. "The physicians would say for themselves, 'We have a lot to offer to make these tools better if only others would just listen and partner with us.' We could all have this be a win-win-win for patients, physicians, and the rest of the health system."
For its part, the AMA is working with both federal officials and EHR vendors to ensure that the voice of physicians is represented in shaping both EHR design and use. While changes to health IT-related mandates will go a long way toward addressing physician burnout, it represents only one of several factors contributing to this phenomenon. That being said, physicians need to strike while the iron is hot to ensure that future clinical quality reporting programs do not repeat mistakes of others.
Case in point: Medicare Access and CHIP Reauthorization Act (MACRA) and its provisions for the Merit-based Incentive Payment System (MIPS).
"There are a lot of moving pieces and a lot things that add to the strain of modern-day healthcare," Stack observes. "But in this area — meaningful use, value-based modifier, PQRS — in the context of MACRA and MIPS, if a program is designed that allows for flexibility so that physicians in their unique practice settings can tailor their compliance with the program to their needs and still be found to be successful in transforming care, then the program has a chance of being more reasonable, more rational, and something that will help physicians and support them in this transformation."
As federal officials at the Centers for Medicare & Medicaid Services (CMS) decide on the particulars of how MACRA and MIPS play out, they have likewise given the provider community ample opportunity to chime in on the regulation and its consequences for physicians.
Near the top of the AMA's wish list is the removal of the pass/fail scoring system.
"The rulemaking for MACRA and MIPS offers the opportunity to eliminate any sort of all-or-nothing, pass/fail methodologies in many of these programs and have things done on a weighted or sliding scale so that if a physician has 15 things they have to do and they fulfill 14 of them, they should get most of the credit. It should not be one of those things where you get 14 out of 15 right and you get a big ol' penalty as the end of the year," add Stacks.
Another is achieving alignment between physician workflows and clinical quality reporting.
"Specialty societies across the country are working in large numbers to create qualified clinical data registries that will allow them to tailor the performance metrics that the specialists are doing so that they are very relevant to improving quality in their unique specialty and also help them improve their clinical processes and get credit for those elements of MIPS," Stack remarks. "In doing that, we can more closely align what the physician is being asked to do with things that the physician finds actually help them improve the quality of care."
At the end of the day, the key to addressing physician burnout, claims Stack, is to ensure that regulation does not force physicians to practice bad medicine. In other words, physicians need to be empowered to practice the most current evidence-based medicine without fear of negative consequences greeting them or their practice down the road. "Those are the kinds of things that profoundly add to physician burnout," says Stack.
"When we are going to get adverse consequences to ourselves or hospitals by complying with the current thinking in medical treatment rather than outdated quality reporting and regulation, those sorts of things are good examples where regulation is not a good tool at times to try to keep up with the fast pace of medical innovation, and good intentions can lead to undesired adverse consequences," he concludes.