Destroy busy work

I wish I could do more paperwork,” said no doctor, ever.

Tasks such as filling out forms, checking boxes and fighting with insurance companies have long irritated physicians. But several trends have converged in recent years to bring what had been simmering discontent over administrative and regulatory burden to a boil. Chief among these are the spread of electronic health records (EHRs) and their accompanying documentation requirements, and the growing number of procedures and medications requiring prior authorizations.

Then, in 2020, the brew of physician frustration grew even more toxic with the arrival of COVID-19. Suddenly, doctors found themselves confronted with a whole new array of health and safety mandates, along with needing to reconfigure their practices to care for patients remotely rather than in person.

The impact of paperwork, regulatory burden

Given these developments, it’s hardly surprising that “too much paperwork and regulations” was the leading cause of burnout cited in the 2021 Medical Economics® Physician Burnout and Wellness Survey. Similarly, 91% of those surveyed by the Medical Group Management Association (MGMA) for its 2021 regulatory burden report said their overall regulatory burden had increased during the previous year — up from 86% in 2018 and 2019.

But even if some administrative tasks are unavoidable in fee-for-service medicine, practice consultants and management experts say there is still much doctors can do to reduce their share of the paperwork load and free up more time for seeing patients.

Tackling the EHR

One of the biggest sources of paperwork and administrative tasks is the EHR. Numerous studies have documented EHRs’ impact on the amount of time doctors spend with patients and their overall workloads. For example, a 2016 study of 57 doctors’ daily activities published in Annals of Internal Medicine found that physicians spent 49% of their total time on EHR and desk work and only 27% on direct clinical face time with patients.

“The EHR has been and continues to be a huge source of added time and frustration for physicians,” says Adrienne Lloyd, MHA, FACHE, founder and CEO of consulting firm Optimize Healthcare and a former MGMA practice consultant. “Most of them understand the need for it from a medical perspective but it’s not a value added from the patient perspective.”

EHRs actually pose three separate, interconnected challenges for physicians in outpatient practices, according to Ron Holder, M.H.A., MGMA’s chief operating officer. First is their lack of user-friendliness, a flaw arising from the fact that they weren’t originally designed for medical purposes.

“A lot of EHRs are really billing systems disguised as a medical record,” Holder explains “So if the technology is designed for simplification of the billing process, that rarely translates into ease of use when working with it clinically.” And while vendors have made some progress in correcting this, many users still find them difficult to navigate and counterintuitive and resent the additional hours of charting they create.

The second problem, says Holder, arises from the frequent mismatch between the needs of outpatient primary care practices and their parent hospital system. “If you’re part of an integrated delivery system it’s likely that the people making the purchasing decisions are buying an EHR that looks good for a hospital, but that often doesn’t translate into being user friendly for an outpatient practice,” he says. “When you take a product that was designed to do X and try and make it do Y it’s going to cause a lot of frustration.”

Finally, when selecting an EHR system many practices don’t consider how it’s going to affect their workflow. “They mistakenly think they can beat the EHR round hole into the square peg of how they’ve always practiced,” Holder says. Ultimately, he adds, most practices find it’s better to tailor their workflows to fit the EHR rather than the other way around.

“You have to be willing to use the tool how it’s supposed to be used,” Holder adds. “It stinks at the beginning, but it gets much easier later on.”

The value of scribes

So what can primary care doctors, and the practices that employ them, do to ease some of the administrative burdens caused by EHRs? A good place to start, and one that’s been growing in popularity, is to use scribes to document patient visits. In a 2018 JAMA Internal Medicine study, 69% of PCPs using scribes reported spending an hour per day less on EHR documentation compared with those not using scribes, 94 % reported greater job satisfaction and 89% reported improved clinical interaction with scribes present.

While some practices balk at the cost of hiring scribes, in many cases they pay for themselves through time savings and added efficiency, notes Owen Dahl, MBA, CHBC, principal of Owen Dahl Consulting. “If I can get, say, $70 for a (CPT code) 99213 established patient office visit, and a scribe allows me to see two more patients per day, then I’ve paid for that scribe,” he notes.

Customize the software

Another technique for improving EHR efficiency, according to Lloyd, is to build order sets and templates. The former consist of services the doctor routinely orders for patients when they reach a certain age or have a chronic condition.

“The EHR generates everything that’s needed (for those services) so the doctor doesn’t have to hunt for each one separately, which makes the process a lot easier for them,” she says.

In a related way, templates enable physicians to standardize and customize their notes, with different fields for vital signs and other things the doctor might want to check,again depending on the patient’s age, gender and chronic conditions. The EHR can then be programmed to use that information as the basis for a note. “So there are ways of building in some automation so the doctor doesn’t have to repeat the same step for each patient,” Lloyd explains.

Sometimes the biggest obstacle to implementing such shortcuts is the doctors themselves, Lloyd says. “It’s getting them to take the time to step back and look at what they do most often so you can build those templates and order sets for them. And it doesn’t take a ton of time; it’s just getting the providers to believe it will help them and getting someone to execute on those things from an IT perspective.”

The technical skills needed for configuring the EHR may require an outside consultant but sometimes a tech-savvy person already on staff is enough. “Even in a small practice often there’s at least one person who can help with configuring the system to what the doctors want and serve as a liaison to the EHR vendor,” she says. “If you’ve got that person it’s a nice opportunity for them to be helpful outside their usual role.”

Enlist patients in the battle

Practices can enlist patients in the effort to reduce administrative burden, says Holder, by encouraging them to submit basic medical information online so it can be seamlessly entered into their electronic medical record.

“I read an article recently that said even motor vehicle departments are better than many practices at getting people to fill out this stuff before they come in,” he says. “When the DMV is being held up as an example you know you’ve got a problem.” Practices buying or switching EHRs can reduce headaches by learning as much as possible about the system in advance, Holder advises. That is best done by talking to other practices who use it. In addition, have vendor representatives spend time at the practice observing how it operates and its patient flow. “Ask them, ‘What would we have to do different in order to efficiently use your system?’” he says.

Reducing the prior authorization burden

The time demands of prior authorizations are another source of frustration for many doctors. In MGMA’s regulatory burden report, 88% of respondents called prior authorization requirements “very” or “extremely” burdensome, up from 82% who used those terms in 2018.

But while prior auths may not be avoidable, experts say there are ways to minimize the burden they impose. One of the most effective, says Dahl, is to compile a running list of which procedures and prescription medications require prior auths from which payers, and under what circumstances. Such information usually can be obtained from the payer’s website and by calling them.

Sometimes, he adds, a payer’s prior authorization requirements will vary even from patient to patient, so it’s important to include the practice’s own prior auth requests and their outcomes. “Don’t just say, ‘We got the authorization’ and leave it at that,” Dahl advises. “Audit what happens with the denials and the authorization hassles encountered. Be aware of the documentation required and ask, ‘Are we providing that documentation and doing so in a timely manner?’”

Analyzing this information usually will clarify which procedures routinely need prior auths from which payers and therefore can be obtained without the doctor getting involved. “I suspect most practices would find the doctor is only needed in about 20% of requests,” he says.

But this process doesn’t relieve doctors of all prior auth responsibilities, Dahl adds. “There’s still some burden on the doctor to make sure what they’re ordering is adequately documented and that there’s sufficient information for the staff to take on the responsibility of communicating with the payer,” he says.

Holder says thorough documentation provides useful ammunition for the times when, even after submitting it, the payer requires a physician-to-physician phone call before it will authorize coverage. “That allows you to say to them, ‘The information is all there in my note. Why am I having to call about this?’” he says.

Negotiating prior auths with payers

Holder adds that prior authorizations can become part of payer contract negotiations by, for example, specifying the circumstances under which the doctor does and does not have to get involved in the process. “You can make the argument (to the payer) that they’re limiting your ability to care for their patients by having to spend time on the phone with them,” he points out.

In addition to EHRs and prior auths, experts say doctors can reduce their non-clinical workload by delegating tasks that don’t require the doctor’s input — and ensuring staff members are trained to do them. Lloyd cites the example of assigning a staffer to take patients’ medical histories before they see the doctor.

“The staffer will need to know what information the doctor wants to have before walking in the room with that patient,” she says. “It’s all about allowing the provider to focus on the areas where they can have maximum impact.”

The ability to delegate effectively also requires strong bonds between doctors and staff, says Holder. “Then people are acting out of loyalty. They know you’re working to make them successful and happy and when that happens the team wants to take as much off the physician’s plate as they can.”

Is AI the solution to documentation woes?

Since computers—in the form of electronic health records—have caused so much of the paperwork burdening primary care doctors nowadays, could they also provide a way to reduce that burden? A project underway at the American Academy of Family Physicians (AAFP) suggests that they could.

AAFP has partnered with Suki, a manufacturer of software that integrates voice recognition and artificial intelligence, to develop AI Assistant for Documentation, a program that combines machine learning — a technology that mimics the human brain’s neural network — and voice recognition software to generate documentation of patient visits.

In December 2021, the AAFP announced results of the second phase of a study of the program’s effectiveness. It found that primary care practices using the program saw a 72% reduction in the median documentation time per note, resulting in a time savings of 3.3 hours per week per clinician. Participants also reported improved levels of job satisfaction and decreased feelings of burnout.

Steve Waldren, M.D., M.S., vice president and chief medical informatics officer for AAFP, said AI Assistant differs from standard voice recognition software in its greater ability to understand voice commands. “You can tell it things like, ‘Suki, change my abdominal exam note to ‘mildly distended,’ and it understands that it needs to go to the physical exam, then the abdomen section, and replace the text that’s there with what you just said.”

Waldren noted the program also can be synced with smartphones and other mobile devices, allowing users to dictate notes whenever and wherever they choose. “The nice thing about leveraging smartphones is that they’ve been designed to enable voice because of features like Siri and Google Assistant, which also means docs don’t have to purchase additional hardware to attain that flexibility.”

The program is available for purchase starting at $199, Waldren said.