The Multiple Layers of Burden

William HymanWilliam A. Hyman
Professor Emeritus, Biomedical Engineering
Texas A&M University,
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I listened to the ONC-CMS Reducing Clinician Burden Listening Session on February 22 which provided the not surprising result that users hate their EHRs on multiple levels and for multiple reasons. The impetus for this meeting was Section 4001 of the 21st Century Cures Act which required that there be a goal of reducing burdens such as documentation requirements relating to the use of EHRs, and that there be a strategy for meeting this goal.

Among the various burdens discussed, there is of course the burden of actually using the EHR as a functional medical record. A good EHR would match and support clinical workflow with locally created content being easy to enter, and perhaps more importantly, all content being easy to find. Yet so many EHRs fail at this most fundamental task. There is also the associated burden of information exchange (interoperability) which can be fairly said to still be in a fledgling state, and which was called “a tremendous broken promise” at the meeting. But what I also learned about from the meeting was the many other burdens associated with EHR use, or in some cases things that could be better addressed with a more functional EHR.

Even before even getting to actual use, there is the burden of selection and roll-out, the latter having been found by many to be awesomely difficult and expensive. There is an inherent relationship between usability and the roll-out burden in that it wouldn’t be so hard to learn how to use it if it was well designed and actually met the user’s needs. Another well-known burden is reporting under Meaningful Use and its new reporting cousins. Reporting is heavy on burden and short on proven value, and this burden has not been lessened by annual changes and new and “better” criteria. It was pointed out by several speakers that one might think (perhaps if one were naive) that if you had to prove that you were using software in a certain way the software itself might know the answer and that there could therefore be automatic reporting. Other kinds of public reporting such as for public health and controlled substances were also mentioned as largely not well supported, and perhaps made more difficult, by today’s EHRs. For many users the burden of selecting a replacement EHR has followed the burden of the selection of the previous one, while it remains unclear of the new one is any better.

Another burden topic was insurance preapprovals and how these could be facilitated by an EHR that “knew” the insurance companies’ requirements, and could automatically seek and record approvals, or flag rejections. Billing and coding were also mentioned as something that could be facilitated by EHRs that actually met user’s needs by incorporating the associated payor requirements and generating the proper output based on the medical care that was presumably recorded in the record. There was some interesting discussion of what billing should be based on such as encounter, procedure, time, complexity etc, all of which are imprecise and open to gaming.

One burden area in which progress has apparently been made is changes in CMS requirements that eliminated the requirement for staff to re-enter student notes. This might be a classic example of the setting of a requirement because of a hypothetical problem without ever determining if there actually was such a problem, and then never determining if a solution “solved” that problem. It can be noted here that it is rather difficult to prove that you solved a problem that you never demonstrated actually existed. In a different arena, that of medical device maintenance, there has been considerable discussions of the creation of rules by CMS that are said to decrease the problem of improper maintenance without ever bothering to show that there was in fact such a problem.

A feature of a “listening session” is that there are no immediate responses so we all have to wait and see what becomes of this effort. Are you optimistic? Fortunately for all concerned, Burden Reduction has been accepted into the HHS Ignite Accelerator which we are assured from its website, has “magic behind it”.