Electronic Health Reporter

Guest post by Jonathan A. Handler, MD, FACEP and chief medical information officer for M*Modal.

The U.S. Government officially recognizes that filling out paperwork is expensive. The most costly paperwork requires us to measure and report information – like our yearly income. If you have ever filled out a government form, you may have noticed that it provides an estimated cost to complete.

For example, the simplest “EZ” income tax form will cost each taxpayer an average of four hours and $40 (http://goo.gl/C6ra — page 41). This is a result of the Paperwork Reduction Act, which requires the government to reduce the paperwork burden on the public and publish the estimated cost of completing each form. However, the Paperwork Reduction Act may have a loophole, because it seems to be limited to government documents.

The government creates a tremendous documentation burden on healthcare providers that appears to fall outside the scope of the Act. In 2014, new government requirements will increase that workload dramatically even as reimbursement drops. Since we do not have consensus on how to address these changes without sacrificing patient care, I believe a key trend in 2014 will be “Managing the Cost of Measuring Care.”

Clinicians are already at the breaking point in the time they spend on documentation and care measurement. This year, regulations demand more than ever. The move to ICD-10 significantly increases the cost of choosing the right billing code because ICD-10 is more complex and about eight times bigger than ICD-9. Stage 2 of the government’s meaningful use program requires clinicians to record more patient information in structured form, to report clinical quality measures, to perform medication reconciliation, and much more. The Two-Midnight rule requires physicians to anticipate when an admitted patient will need to stay in the hospital longer than “two midnights” and justify that in writing.

Regulators are further amplifying the cost of documenting and measuring care by accusing clinicians of fraud if they utilize simple, common time-savers such as templates and even basic copy/paste. Adding insult to injury, payors are continuing to reduce reimbursement for care, in some cases dramatically. If the cost of measuring care rises while reimbursement falls, how will we address the gap without shortchanging patients? There is not a well-accepted answer, so providers will spend 2014 exploring a wide range of options.

Some will turn to technology and services to reduce the workload of measuring care. Speech recognition software can speed up documentation. Natural language processing software (NLP) can convert free text into structured data to support meaningful use Core Measures and other documentation needs. Automated real-time feedback powered by NLP can help clinicians ensure that the documentation is complete enough on the first pass to support the required measures of care, even in an ICD-10 world.  Others will turn to people for help. Transcriptionists and scribes (both remote and on-site) can dramatically reduce documentation time. As the cost of measuring care increases this year, we may see a resurgence in these clinician support services.

Some institutions will increase their use of mid-level providers. Used appropriately, mid-levels can provide care at half the cost of a physician. That enables mid-level providers to document all the care measures and codes without raising costs or cutting into caregiver time at the bedside. On the other hand, faced with declining pay, job stability, and work satisfaction, some physicians will opt out of the traditional system and embrace concierge medicine. This model charges patients a yearly (or monthly) fee in return for premium service with greater access to care. These physicians will either use the retainer to support the time costs of measuring care, or to weather the penalties of not participating in the government programs.

Perhaps most interesting of all will be combinations of these various options. Caregivers might use speech recognition and/or transcription combined with NLP to provide the convenience and richness of free text while still creating the structured data required to support the measurement of care. Perhaps the ultimate combination would be physicians overseeing mid-level providers who are supported by scribes and/or transcriptionists that use speech recognition combined with NLP. Such a highly-tiered system will succeed as long as the efficiencies gained outweigh the overhead of measuring care.

It’s not clear which approach will win in the end. Those who participate in the government incentives may take a different path than those who opt out. In any event, one 2014 trend seems clear: Providers will innovate in managing the cost of measuring care, and that’s a win for everyone.