American Medical Informatics Association (AMIA) January 28 call for The US Department of Health and Human Services (HHS) will adopt a long-term strategy for electronic health records that "dissociates clinical documentation from billing, regulatory and administrative compliance requirements."

Commenting on HHS 'new roadmap to reducing the regulatory and administrative burden of EHRs and health information technologies, Douglas B. Fridsma, MD, President and CEO of AMIA, stated that his organization supported the objectives set out in the clinical documentation section of the strategy paper.

"However, we recommend that CMS [the Centers for Medicare & Medicaid Services] chart a path to more dramatic E / M [evaluation and management ] reforming the documentation guidelines – or abandoning the methodology altogether, "he wrote in a letter to CMS officials and the Office of the National Coordinator of Health Technologies (ONC), which developed the strategy. .

The CMS E / M documentation system, which is also used by private payers, "does not capture the complexity of the patient's clinical condition, relevant clinical decision-making, and the heavy administrative demands of patient care. "said Fridsma. .

To comply with the E / M coding requirements, he noted, much of the "unnecessary and redundant information is recorded", which is not only a waste of time, but also prevents clinicians from finding information. important in patient records.

Instead of continuing to follow current E / M guidelines, AMIA recommends that CMS bring together specialty companies and health informatics professionals to develop new E / M coding criteria and reorganize EHR to adapt them.

This would be a giant step beyond what CMS has already adopted with the E / M guidelines. In November, as part of the 2019 update of the physician fee schedule, the agency announced the phased implementation of a plan to simplify billing office visit requirements. Starting in 2021, CMS announced that Level 2, 3, and 4 billing E / M codes would be reduced to one. This will leave three E / M codes, including level 1, which does not involve the services of a physician, and level 5, designed for patients with complex conditions that take longer and work.

In addition, under the new regulations, physicians will be able to use the complexity of medical decision-making or visiting time, instead of current E / M guidelines, to justify their coding E / M. Doctors who continue to follow the E / M directives will not have to re-record the list of required items at each visit if the doctor attests to have reviewed the previous data.

Change the design of the EHR

According to Mr. Fridsma, the main obstacle to the ONC roadmap is the structure of the current EHRs. "Most EHRs are designed to support for-for-service (FFS) billing requirements and business processes for regulatory / administrative compliance, rather than reflecting clinical observation and treatment."

EHRs were obtained in this way in part because they were initially sold to physicians, believing that better clinical documentation would warrant higher E / M codes and thus higher payments. But the AMIA chief said that the current design of the EHRs can be attributed in part to Medicare regulations, such as the conditions of participation, the CMS claims handling manual and the annual "work plan" of the Office of the Inspector General (OIG) of the HHS. The merit-based incentive payment system (MIPS) and the CMS interoperability promotion program have also made EHRs more complex.

For example, Fridsma said, the conditions for participation in Medicare include a leave planning regulation that specifies a multi-step process for hospital discharge planning, which needs to be reflected in the EHR. The OIG work plan focuses on adverse events in hospitals, including the clinician review processes that need to be integrated with the EHR. And the data that needs to be reported to MIPS does not necessarily reflect the clinical case of the patient, but it does require complex documentation at the point of treatment, he said.

According to Fridsma, decoupling documentation used for clinical care purposes from these administrative and regulatory requirements "can significantly reduce the clinical burden". Changing or removing the E / M directives is the key to decoupling, he said. "Greater reform [of E/M coding] or the development of a new approach should be the central workflow towards the decoupling of clinical documentation from the billing requirements. "

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