Taking Action Against Clinician Burnout A Systems Approach to Professional Well-Being (2019) / Chapter Skim
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6 The Influence of the External Environment on Clinician Burnout and Professional Well-Being
6 The Influence of the External Environment on Clinician Burnout and Professional Well-Being
Pages 167-198
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, regulatory, and social factors in the external environment that affect health care organizations (HCOs) and contribute to workplace stress and greatly diminish clinicians' professional well-being.
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changing societal THE EXTERNAL ENVIRONMENT LEVEL OF THE SYSTEMS MODEL OF CLINICIAN BURNOUT AND PROFESSIONAL WELL-BEING gulations, and , Re Sta ws nd | La ar ry ds st du |S In oc are iet al th C Val Heal ues | Frontline Care Delivery | Health Care Organization | External Environment FIGURE 6-1 The external environment level of the systems model of clinician burnout and professional well-being.
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in the context of some of the policies associated with clinical documentation, prescription drug monitoring, prior authorizations, and information privacy and security. Chapter 7 takes a broader view of the role of health IT in clinical practice, its effects on clinicians, and the innovations under development.
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1957) Care delivery strategies such as standardization, cost controls, and productivity targets can create schisms between individual clinicians' values and expectations and those of the organization as well as declines in the clinicians' sense of control, flexibility, and autonomy and a potential erosion of professional values (Casalino, 2017; Moses et al., 2013; Rastegar, 2004)
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. In the sections that follow, the committee discusses various laws and regulations that define payment schemes for clinician services and that shape the requirements, policies, and procedures for medical records documentation and coding, quality measurements and reporting, prescription drug monitoring, privacy rules, and prior authorization forms.
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, and using information technology to improve patient care. A goal is to substantially change incentives to promote the delivery of higher value care by clinicians and HCOs.
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lead and expand the use of risk-sharing contracts (Health Care Transformational Task Force, 2017; Hsu et al., 2017) , one result could be greater clinician burden because of the variations across payers in terms of programmatic goals, documentation and performance measurement requirements, and uncertainty about the evolution of payment models (Hsu et al., 2017)
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he medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient's progress and response to medications and services" and provides further detailed requirements to meet this standard.5 Additionally, the federal Meaningful Use program has expanded medical records documentation requirements to include specific information pertaining to payer quality measures6 and to serve as a vehicle for sharing health information with patients, families, and caregivers.7 Appendix B provides examples of the clinical documentation and coding requirements of the Medicare Program, for accreditation by The Joint Commission, and of the ICD-10. State medical boards also may require certain clinical documentation requirements, for example, with respect to a telehealth encounter.8 Other stakeholders have placed additional requirements on the clinical documentation process for quality reporting, physician report cards, reimbursement, 4 See, e.g., Illinois Administrative Code, Title 77 Public Health, Chapter 1: Department of Public Health, Subchapter b: Hospitals and Ambulatory Care Facilities, Part 250 Hospital Licensing Requirements, Subpart L: Records and Reports, Section 250.1510(b)
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. Federal actions to reduce the effort and time required to record health information include the development of a draft Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Health IT and EHR (ONC, 2018)
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. In AMIA's view, efforts to improve clinical documentation and reduce clinician burden should focus on clinically purposeful documentation and not just on reduced documentation (Fridsma, 2019)
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Quality Measurement and Reporting Documenting and reporting quality measures is of paramount importance to improving health care. Two Institute of Medicine reports, To Err Is Human: Building a Safer Health System (IOM, 2000)
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In addition, the Core Quality Measure Collaborative (CQMC) , involving America's Health Insurance Plans, CMS, and NQF, as well as national physician organizations, employers, and consumers, promotes the coordination of measure use and collection across public- and private-sector payers. In developing core sets of performance measures, CQMC aims to "reduce the burden of measurement by eliminating low-value metrics, redundancies, and inconsistencies in measure specifications and quality measure reporting requirements across 12 Consumer Assessment of Healthcare Providers and Systems (CAHPS®)
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. Prescription Drug Monitoring Program Requirements Currently, 49 states, the District of Columbia, and one U.S.
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. The steps required by clinicians to comply with federal and state privacy and security laws and regulations concerning health information along with related organizational policies and procedures add to the administrative burden on clinicians.
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. Prior Authorization Process Payers often require clinicians to obtain prior authorization for medications, other forms of treatment, diagnostic procedures, and referrals.
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. These stake olders h identified five areas for improving the prior authorization process: the use of criteria for the selective application of prior authorization requirements; regular review of the list of medical services and prescription drugs that are subject to prior authorization; enhanced communications among health plans, health care providers, and patients; continuity of patient care; and widespread industry use of standard electronic prior authorization processes.
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In a 2016 review of initial and renewal medical license application forms from 48 medical licensure boards, 50 percent were found to have included overly broad questions about physicians' mental health that were inconsistent with the AMA, the American Psychiatric Association (APA) , and the Federation of State Medical Boards (FSMB)
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. Some analyses have concluded that many state medical and nursing licensing board questions about past, rather than current, histories of mental illness and substance abuse are likely in violation of the Americans with Disabilities Act (ADA)
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. In 2018, the FSMB issued 10 recommendations related to the state medical board licensing process that were intended to reduce the stigma associated with mental health issues and encourage treatment seeking (FSMB, 2018)
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. Several states recently have adopted, or are actively considering, the recommendations of the FSMB and the AMA, including the state medical boards of Florida (Freeman, 2019)
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. Professional Liability Similar to medical licensure, obtaining professional liability insurance often requires completing forms that include questions inquiring about past and current mental health concerns, presenting yet another barrier to appropriate treatment seeking.
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. As the regulation of digital health technologies continues to evolve, the evolution may affect whether a negligence standard or product liability will apply in a medical malpractice claim.
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. There is concern that health care rating websites targeting patients are not accurately reflecting these structural changes in care delivery.
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https://www.acponline.org/acp_policy/ statements/joint_principles_administrative_burden_2018.pdf (accessed July 20, 2019)
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2018. Consensus statement on improving the prior authorization process.
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2019. Cerner to work with DrFirst to connect to state prescription drug monitoring programs.
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2014. Interstate medical licensure compact ready for consideration by states: Federation of State Medical Boards.
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:640–648. Interstate Medical Licensure Compact.
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New York Times, June 8. https://www.nytimes.com/2019/06/08/opinion/sunday/hospitals doctors-nurses-burnout.html (accessed July 20, 2019)
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2009. Do state medical board applications violate the Americans with Disabilities Act?
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2018. Association of the use of a mandatory prescription drug monitoring program with prescribing practices for patients undergoing elective surgery.
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