Opinion: EHR Reform Requires Clinical Note Reinvention to Cut Clinician Burnout

Removing all financial and administrative functions from patient-clinician interactions is essential for EHR reform to mitigate clinician burnout, according to a viewpoint article published in JAMA Network Open.

In 2020, the American Medical Informatics Association formed a group called “25 × 5” to reduce clinician documentation burden by three-quarters over the next five years.

A 2022 workshop allied with the 25 × 5 initiative identified six major EHR issues:

• Failures to achieve interoperability (in part to the absence of a unique personal identifier)
• An inadequate personal health digital infrastructure
• An inadequate public health digital infrastructure
• Insufficient attention to diversity, equity, and inclusion
• Weak privacy, endangering safety
• EHR design, configuration, and implementation issues

The JAMA viewpoint authors identified four issues as most striking and three as most actionable.

“The continued lack of nationally used unique personal safety identifiers for health as originally mandated in the HIPAA (Health Insurance Portability and Accountability Act) in the mid-1990s presents a continuing threat to privacy, safety, cost reduction, and administrative errors while remaining the least likely to be corrected,” they wrote.

They suggested three more actionable course corrections for EHRs needed in this decade: removing all administrative and regulatory content from “clinical time” unless such content is the primary clinical issue, including patient-entered information in the EHR, and reinvention of the clinical note.

“A relentless policy and a technical effort must lead to removal of all financial and administrative functions from direct patient-clinician interactions,” they wrote.

Exceptions to this procedure should occur if administrative data are an immediate patient concern, the authors said.

“Although it is difficult to separate payment models and other administrative requirements from clinical documentation, this is essential because they are currently associated with many of the frustrations that clinicians and patients face,” the authors emphasized.

“All prior approval or authorization practices should be reviewed to determine whether they can move to an audit approach post hoc or be removed,” they continued. “If they are still required in some circumstances, streamlined methods must be developed.”

The authors said that to make this happen, CMS should reform its requirements to remove all such intrusions into the clinical encounter.

They suggested that metadata, audit trails, and log files associated with clinical encounters could replace repetitive documentation.

Like billing requirements, quality measurements should not create documentation burdens.

“Other third-party payers should and likely will follow CMS’s lead,” the authors said. “More broadly, health information technology developers must invest the time and resources to make such data accessible without placing any demands on clinician time.”

Additionally, they pointed out that patient-entered data must become a natural part of the record and be accessible for analysis.

“Despite the multiple challenges this change will present, meaningfully incorporating patient-derived data as part of the record deserves aggressive experimentation and ultimate mainstreaming as practical paths develop,” the authors wrote.

However, they pointed out that including patient-entered data and removing administrative tasks from the clinician’s work will “only mitigate the currently diseased EHR.”

The authors noted that the clinical note should be prospective in focus, meaning it should speak to desired results of recent clinical action and may include expected timelines.

“All hard stops during the ordering process in hopes of added patient safety should be examined critically, so they may be either minimized or eliminated,” the authors said. “Clinicians functioning as billers will need to ‘unlearn’ unnecessary patterns of documentation, with less documentation being the norm rather than more.”

They noted that additional efficiencies could blossom with regulatory-driven documentation requirements removed from patient care.  

For instance, accurate medication and allergy lists could be reimagined by developing a cloud-based definitive list for a patient, curated and validated by pharmacists.

“CMS already has statutory and regulatory authority to implement large-scale demonstration projects to test these changes,” the authors wrote. “Where this is not the case, we call on the legislative branch to authorize proposals. If needed to overcome inertia, a government-mandated and -funded evaluation and report from the National Academy of Medicine deserve serious consideration.”

“Although addressing shortcomings in EHRs will not cure all that ails our current healthcare system, implementing these recommendations should positively affect patients and clinicians and move us toward the original vision of a patient-centered, technology-enhanced healthcare ecosystem that is designed to significantly improve outcomes at a lower cost, with more satisfied patients and clinicians,” they concluded.