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'First, To Do No Harm': Dr. Michael Murphy on how CMS' new rules could backfire

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We've come a long way from the notoriously illegible, handwritten doctor's note. Does it read "sepsis" or "sinus"? The implications of choosing one versus the other are enormous.

When I became an emergency medicine physician over a decade ago, finding a way to streamline medical documentation was slowly becoming an imperative for physicians and patients. Communication among physicians improved, as did care quality once Electronic Medical Records grew in popularity. By 2015, all public and private healthcare providers were required to adopt and demonstrate meaningful use of EMRs in order to maintain full reimbursement from CMS. The new legislation created a universal language for medical professionals and marked a sea change in healthcare delivery.

As with many innovations, the unintended consequence soon became evident. Although being rid of the handwritten note lessened confusion, and the streamlined documentation process added a level of standardization, the adoption of EMRs created new, time-consuming and tedious clerical work for the physician. Requiring physicians to complete the documentation in charts added a level of administrative burden never before seen in the practice of medicine or taught in medical school. And tying reimbursement to documentation translated into long hours spent at the office working on suspended charts. The upside was streamlined care, the downside — burnt out physicians.

Today, physicians are leaving the medical profession in record numbers due to the burden of documentation that has led to decreased job satisfaction. The doctor's decree, Primum non Nocere, or "First, to do no harm," must be evoked to protect the providers themselves.

Yet, with the proposed policy recently released by CMS in July, the pendulum has swung back too far. While I commend CMS Administrator Seema Verma for confronting this enormous challenge, I fear reducing the levels of documentation needed for accurate patient care and reimbursement will have unintended adverse consequences.

Under the current payment policy framework, when patients visit their doctor, the physician reviews the symptoms, and the interaction is given a code Level 1 to 5 to be input into the patient's medical chart. The evaluation and management codes determine the reimbursement level for the physician's services and resources used to treat the patient. Level 1 is used for non-physician care team members, when the presenting problems are minimal, while Level 5 denotes more complex care. In order to be reimbursed accurately by CMS, doctors must provide documentation that reflects the level of Medical Decision Making and time spent face-to-face with the patient to assess next steps.

In an effort to correct the epidemic administrative burden threatening to derail an industry in critical condition, CMS has proposed physicians no longer document beyond Level 2 payment. Physicians would be allowed to document up to Level 2, or base reimbursement, solely on face-to-face time spent with patients, with a set minimum time for physicians who choose to code the visit by time alone. The hope is that a reduction in the number of documentation levels would curtail a growing trend of physicians leaving the profession, unwilling to spend their careers inputting patient data, instead of practicing medicine.

While the proposed rule reduces the E/M documentation burden and thus could save physicians time, scaling back too far by conflating four levels of documentation into a single documentation level is a drastic move that may be fraught with peril. Burnout is real, and we do need a streamlined process, but at what cost and to whom?

Can you imagine the potential for mistreatment or misdiagnosis by referring physicians down the care continuum if the original provider documents to the level of a common cold when in fact the patient had chest pain?  Thin documentation could also increase costs to patients and payers. If tests such as an MRI were ordered and not documented, referred physicians may re-order the tests again unnecessarily. In addition to the attendant risks noted above, the new rule, like a time warp, instantly moves us backward in time to the days of inadequate documentation. What's next, go back to ICD-9? In one fell swoop, the new rule could unwind many of the strides that we've made over the last 20 years.

In addition to patient harm, the new rule would have legal ramifications for physicians. How will such a light note be defended in a legal trial? And if the enhanced patient risk, legal risk and an anachronistic approach weren't enough, the new rule will likely introduce fraud into the system. If we reduce documentation, will providers honestly spend more time with their patients, or will some simply utilize the time savings to see more patients to keep revenues the same or higher?

As the CEO of HealthChannels, an organization working on the front lines of healthcare to alleviate the clerical burden doctors face to allow them to work top-of-license, I have seen how effective a medical scribe program can be when scribes are paired elbow-to-elbow with providers. From work RVU's to technology-based solutions, optimizing care teams to support providers doesn't have to be financially onerous. Our clerical programs routinely result in providers having more time with patients (and for themselves) with the use of medical scribe support.

Another solution is to implore EMR companies to streamline their product as an imperative: less clicks is a good thing for all providers. Patient documentation became burdensome when EMRs were mandated. The problem is not the E/M Levels themselves, but a broader need for better designed EMRs.

What if CMS told the EMR vendors to streamline their product by 20 percent fewer clicks by 2020 or face a hefty penalty? Also, mandating interoperability so that EMR systems share data between providers and hospitals would modernize the current, frustratingly siloed documentation experience. Finally, CMS should allow other members of the care team to place orders, do medication reconciliation and perform other ancillary duties so physicians can be relieved of these burdens.

If a pendulum swings too far in one direction, what we know from experience is that it is only a matter of time before it swings back. Delivering accessible, quality and affordable care is a shared goal for those of us in the medical profession. Though I am glad CMS is keen on protecting physicians and the profession, I remain unconvinced the new rules will do no harm.


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