Making lemonade
How can dermatologists utilize burdensome EHR systems to their advantage to enhance patient care?
Feature
By Andrea Niermeier, Contributing Writer, August 1, 2024
When a medical student imagines their life as a doctor, they may visualize themselves perched on a swiveling chair in an exam room, building rapport with the patient, or huddled in a meeting room discussing challenging cases with colleagues. One place they may not see themselves is in front of a computer screen doing paperwork. Yet for dermatologists, computers have become an essential part of the workflow of treating patients. Since the American Recovery and Reinvestment Act in 2009, employing electronic health records (EHRs) has become a standard in many practices, but it’s been an adjustment.
Ivy Lee, MD, FAAD, chair of the American Academy of Dermatology (AAD) Augmented Intelligence Committee, reflected on the development of this technology. “When there is new technology to be implemented in very specific domains such as health care and specialties like dermatology, having physicians with a voice and seat at the table early on is extremely important. That did not happen with EHRs.” As a result, physicians have had to adapt their workflows, sometimes with costly consequences. According to a survey of AAD members between 2016-2020, one of the most pressing administrative burdens is EHR documentation, with roughly an additional six hours added to a dermatologist’s work week. Moreover, office administration duties have added roughly three hours, and practices are spending an average of $40,000 a year on specialized staff to help manage the process. Dr. Lee stated, “What was intended to help us has contributed to lower job satisfaction and burnout in our careers.”
While EHRs have undoubtedly caused widespread headaches in the health care arena, how can physicians take advantage of the technology? “Being thoughtful and smart about how we interact with EHRs can make them a strength in our practice rather than a burden,” said John Barbieri, MD, MBA, FAAD, chair of the Academy’s Drug Pricing and Transparency Task Force. Dermatologists and practice management experts discuss the various ways physicians can utilize EHR systems to improve patient care.
Access the Academy’s prior authorization tool
One type of software that can be integrated into EHRs is electronic prior authorizations (ePA). Although prior authorizations used to be relatively rare and typically required for high-cost or complex medical procedures, health insurance companies are increasingly utilizing prior authorization as a tool to manage costs. The process of obtaining prior authorizations has also become more complex and time consuming, requiring physicians to supply stringent documentation for medication, diagnostic tests, surgery, and specialist referral requests.
In a 2020 AAD survey about prior authorizations, dermatologists estimated that about 25% of patients require prior authorization. Among patients not approved for prior authorizations, 27% experience a delay or abandon treatment, with the remainder forced into step therapy or alternative treatments. In the time needed to complete these prior authorizations each day, physicians estimate that they could have seen an additional five to eight patients. “This indirectly contributes to access challenges and creates bloat in health care costs,” Dr. Barbieri explained.
Identifying prior authorizations as a significant burden on members, the AAD developed the prior authorization appeal tool. The tool allows physicians to create customizable letters with medical rationales and references written by AAD members. Dr. Barbieri commented, “The letters in the tool are created by experts, so they have a lot of references and text by someone who is really good at getting that drug approved.”
Not only do the letters provide robust clinical documentation, but content is revised annually by AAD members. Currently with support for over 65 common dermatologic drugs for various diagnoses, the tool has new FDA-approved drugs added regularly. To protect PHI, the AAD does not save or share with any entity the information added into the prior authorization tool. “One of the most useful aspects of the letters is how they are made. A lot of expertise and thought goes into them that can help people learn to be more successful at writing prior authorizations and potentially getting approved the first time,” said Dr. Barbieri. Access this top-performing tool in the Practice Management Center.
Standardized data collection
Even though health care professionals have identified EHRs as a source of frustration, Faiza Wasif, MPH, Academy associate director of practice management, acknowledges that the technology has transformed health care over the last decade. More than just reducing physical space requirements and time spent searching through paper records, EHRs have streamlined documentation with templates designed to reduce administrative tasks and standardize the data captured. A faster way to record a patient’s condition, many templates can be tailored to practice needs, focusing on specific measures, guidelines or conditions already used in the practice. In addition, they can be geared toward guidelines, protocols, pre- and post-procedural matters and post-discharge requirements. Dr. Barbieri recognized the investment that clinicians must make to harness EHR potential. “Spending an hour setting it up to save 10 hours in the future is something we likely could do more.” Using the EHR program templates to their fullest potential can perhaps alleviate some strain, and Dr. Barbieri suggests dermatologists can learn a lot from each other’s best practices to get the most out of the EHR.
“Trying to mount a Maserati engine on a Conestoga wagon doesn’t work. We can look through a different lens about why information is important and, as a specialty, come to a consensus about what information to base decisions off of and how best to collect it.”
This opportunity for more efficient charting also requires a commitment to high-value data. Dr. Lee commented on derm-specific EHR templates. “We find a lot of cut and paste repetition that accumulates with every visit. I do not want to sort through copious text and legalese. Instead, I want distilled, actionable information that captures pertinent positives and negatives and encapsulates the patient’s needs so I can move forward with a proactive, personalized plan to keep a patient well.”
To do this requires careful thinking in terms of what, how, and where. Robert Swerlick, MD, FAAD, chair of the AAD DataDerm Oversight Committee, noted that the initial strategy of EHR vendors was to emphasize the improvement it could bring to collections and billing. Rules from the mid-1990s about justifying billing at various levels primarily had to do with the amount of information, resulting in notes for American physicians being three times longer than anywhere else in the world. This can be made worse with templates. “Note bloat causes a ‘Where’s Waldo’ problem — a struggle to find that striped shirt because of the irrelevant stuff around it.” To ease this burden, Dr. Swerlick discerns an opportunity to rethink the informational world on a fundamental level. “Trying to mount a Maserati engine on a Conestoga wagon doesn’t work. We can look through a different lens about why information is important and, as a specialty, come to a consensus about what information to base decisions off of and how best to collect it.” To help improve note bloat, Dr. Barbieri suggested clinicians evaluate whether the information they are adding speaks to the purpose of care coordination, billing and prior authorization, and medical-legal justification.
Open pathways for communication
Not only have EHRs helped to streamline data collection, but they have also opened up channels of communication among physicians and between physician and patient. Dr. Lee commented on the benefits, noting that while work still needs to be done toward full interoperability, current technology allows transfer of information in a more standardized way as patients move through care systems and interact with different inpatient and outpatient health care settings. Highlighting this point, Dr. Barbieri acknowledged that coordinating care is much easier than in the pre-EHR era, helping clinicians better understand someone’s comprehensive medical history, medicines, and allergies as well as improving the process to communicate with other health care professionals.
Wasif noted that before the widespread adoption of EHRs, patient communication with health care professionals primarily occurred through phone calls or in person. Patient portals help to empower patients, offering convenient access to update information, exchange HIPAA-compliant messages, schedule appointments, request medication refills, and access health records, often from their mobile device. With this advancement in health care, physicians have also had to figure out how to manage the flood of communication associated with this increased patient engagement. “One of the pain points I hear from physicians is about the significant amount of time and cognitive burden associated with the amount of messages in the patient portal. Often there is an unrealistic or unclear expectation of response time,” Dr. Lee admitted. However, she also highlighted the solutions being developed for inbox management; tools like artificial intelligence (AI) may ingest, summarize, and draft an initial response to patients.
In addition to advances in patient-physician communication beyond appointments, Dr. Lee feels hopeful about AI’s potential to improve the patient’s experience during the appointment. Prepopulated information gathered ahead of an appointment could help physicians know what they need to cover and how it relates to the patient’s history. “Instead of hiding behind my laptop or charting stand during the appointment, it would be great to have ambient documentation that summarizes the encounter for documentation, coding and billing, and care coordination. This can be liberating and allow for natural conversation and better rapport building throughout the patient’s journey in treating disease and promoting wellness.” She emphasized that those same tools could potentially summarize the visit and provide culturally aware and actionable takeaways for patients. “I think those solutions already exist today, but they have not been integrated into the patient journey yet. We must be collaborative in co-creating safeguards, regulation, reimbursement, and liability policy for AI because these aspects of the implementation infrastructure are critical for sustainability and scalability.”
DataDerm™ for improved MIPS compliance
Adding to the workload of documentation for dermatologists is meeting Merit-based Incentive Payment System (MIPS) compliance requirements. Dr. Swerlick acknowledged, “Physicians end up inputting information when they see patients, requiring them to solve problems and be data entry clerks at the same time.” The time-consuming nature of preparing for MIPS reporting can include selecting the criteria for relevant measures for a practice, maximizing points to avoid penalties or qualify for an incentive, ensuring staff accurately document criteria for eligible patients, and confirming patient data is accurately and fully integrated into the practice’s selected MIPS reporting mechanism. According to an AAD member survey, MIPS compliance typically makes up more than 75% of a practice manager’s responsibilities due to the program’s complexity and the need to stay updated on annual requirements.
Failing to meet the MIPS requirements thoroughly or promptly can come with serious consequences — a penalty of up to 9%. To ease this burden on a practice, the AAD developed the Qualified Clinical Data Registry DataDerm™ that facilitates reporting for Quality, Promoting Interoperability, and Improvement Activities and offers dermatologic insights not available through any other MIPS reporting mechanisms.
DataDerm offers integration with EHRs which can map required DataDerm data elements and utilize DataDerm-specific measure templates, eliminating manual entry for quality measures. “The dashboard lets practices know how they are doing on those various metrics in as near real-time as possible,” Dr. Swerlick added. See a complete list of EHRs that work with DataDerm.
DataDerm’s tailored customer service and dermatology-specific platform can enhance workflow, clinical documentation, and practice management. Now transitioning to an AAD-owned platform for its clinical data registry, DataDerm is partnering with PA Consulting to add new features, expand performance measures, and integrate future functionalities beyond MIPS reporting.
Clerical solutions
Another way that EHRs can integrate AI technology to reduce documentation burdens is through AI-powered clinical digital assistant programs. For a while, dermatologists have used in-room scribes contracted with companies to help with those responsibilities, and some companies even provide e-scribes who are trained in certain EHR systems to enter notes in real time from a remote location, allowing practices to avoid onboarding new employees.
Adding to these options, Wasif noted that voice recognition software (VRS) enables physicians to seamlessly engage with patients while simultaneously transcribing patient encounters and facilitating the review and addition of notes to the patient chart. “VRS applications often enhance their performance with each use, adapting to individual voices and preferred terminology over time,” she highlighted about their evolving accuracy. Recently the AAD commenced a 45-day pilot project with the AI-powered voice assistant Suki to evaluate its effectiveness in reducing clinical documentation burden. The pilot used Suki’s ambient feature to allow participants to continue their workflow with Suki operating in the background. The project validated the benefits of VRS to enhance practice management.
These VRS tools offer many of the same benefits as scribes in patient satisfaction and physician burnout. Doctors spend less time making notes, reducing the time spent outside of office hours updating EHRs and increasing job satisfaction and quality of life for physicians. In turn, patient wait times are reduced and dermatologists can better engage with patients during appointments, also increasing patient satisfaction. Maximum staff efficiency and optimal documentation for billing are also benefits. However, Wasif warned that practices should obtain patient consent before utilizing the technology during a patient visit. In addition, practices must ensure electronic patient health information (ePHI) is protected and any consent for data usage and storage is transparent.
Although scribes and VRS are some solutions to the strain of documentation, practices need to evaluate their budget to determine how much they can allocate not only to these remedies but the entire EHR system. Wasif explained that server-based systems may have higher upfront costs but lower long-term expenses. Cloud-based systems offer subscription models, potentially reducing labor and maintenance, but often with fixed subscription fees. Also, practices should consider hidden expenses like licenses and training for all documentation decisions.
When it comes to the future functionality of EHRs and development of other technology that may help ease the burden of documentation, dermatologists must take their seat at the table with EHR vendors, regulatory bodies, and professional associations to participate in the decision making that will ultimately impact the way they care for their patients. “Bridging these communities of clinicians, who possess the intimate knowledge of the clinical needs and are also the end users of these tech tools, with other stakeholders is vital to identifying and measuring the right outcomes. Only after we can show these improved outcomes and metrics of impact, will we have a truly valuable tool for patient care,” Dr. Lee elaborated. Most importantly, both current and future dermatologists must imagine themselves as important pieces of the puzzle in developing new health care technologies. Dr. Swerlick reminded, “It falls upon dermatologists to define what good looks like and what success looks like in conjunction with our patients, who are ultimately the source of understanding whether their needs are met or not.”
