AAPA’s new EHR Toolkit can help PAs advocate for EHR systems that are designed, selected, and implemented with functionality considerations for PAs, ultimately resulting in more efficient and high-quality patient care. AAPA’s EHR Toolkit contains five resources to help PAs. Contact Sondra DePalma at [email protected] for more information.
Best Practices Checklist for Your EHR System
Optimal PA Utilization of Electronic Health Records
- There is someone in the organization with whom a PA can speak regarding questions or concerns about the design, implementation or functionality of the electronic health record (EHR) system.
- All professional services delivered by a PA are captured by the EHR.
- All professional services delivered by a PA can be tracked and attributed to the PA via the EHR, even when those services are billed under a physician’s name.
- A PA is able to obtain a report from the EHR system for all of the services he or she delivered.
- If a physician co-signature is required, the professional services a PA provided and documented will be attributed to the PA provider of service.
- The EHR system does not contain requirements that are more restrictive or prohibitive than federal or state law (e.g. co-signature requirements or limitations on writing orders/prescriptions) unless specified by practice or facility policy.
- If a PA practices in more than one specialty, the PA will have access to EHR functionality appropriate to his or her scope of practice, credentialing and privileges for each specialty.
- The requirement of a physician co-signature on one type of an order does not create an automatic requirement for a physician co-signature on other types of orders (e.g., a requirement for a physician co-signature on a controlled substances order does not necessitate a physician co-signature requirement on all medication orders).
- A PA can view changes, corrections, and/or addendums to the patient’s medical record made by him or her and other health professionals with access to the medical record.
- The EHR system can be modified based on feedback from PAs and other health professionals, to improve use, operability, and compliance.
Electronic Health Records and PAs:
Best Practices for EHR Vendors
PAs (physician assistants) are state-licensed medical professionals who deliver medical and surgical services, as authorized by state law. PAs are integral members of the healthcare team and need access to electronic health records (EHRs) to effectively deliver care to patients.
- More than 123,000 PAs practice medicine and prescribe medication in all 50 states, the District of Columbia, U.S. territories, and the uniformed services. Employment of PAs is projected to grow 37% from 2016 to 2026, much faster than the average for all occupations.1
- In 2016, PAs were responsible for an estimated 475 million patient visits.
- The Affordable Care Act recognized PAs as one of three primary care providers (along with nurse practitioners and physicians) and empowered PAs to lead patient-centered medical teams.
- PAs are individually credentialed and privileged by hospitals to deliver a wide range of medical and surgical services.
- In the office setting, PAs often have their own schedule and panel of patients, and practice with a high degree of autonomy.
EHR Best Practices
An increased focus on team-based care will require health providers to utilize EHRs to achieve optimal care coordination. However, some EHRs are currently designed in a way that limits effective use by care providers such as PAs. Such EHRs would benefit from modifications that encourage and facilitate PA functionality, transparency, and regulatory compliance. We identified the following three principles to ensure effective EHR utilization:
1) EHR systems must be able to identify, track, and quantify work performed by PAs and other providers2.
a. Requires accurate attribution of patients, orders, test results and care provided, even when a
service is performed in conjunction with, and billed under, a collaborating physician.
b. Attribution of notes in a medical record should not be changed from the original author (e.g., the PA) if a different health professional subsequently treats the patient or modifies/makes addendum to the note.
2) EHR vendors must include PAs as part of the healthcare team that provides input into the design, build, testing, implementation, and ongoing management of EHR systems, in order to identify key aspects of PA operability which might otherwise be overlooked.
3) EHR systems must be adaptable to take into account the individual clinical practice requirements of each health professional, including PAs.
a. Hospitals, medical practices and health systems must be able to modify level of access granted, as well as EHR requirements, for all health professionals who use the EHR, including PAs, in order to account for a health professional’s specialty, scope of practice, and privileges.
b. Specifying a requirement in the EHR should not automatically apply this requirement elsewhere (e.g., a co-signature requirement for controlled substances should not automatically create a co-signature requirement for non-controlled substances or the writing of orders).
When designed and implemented in a manner that properly accounts for PAs, EHRs can encourage transparency, improve quality, increase patient safety, enhance operational efficiencies, provide cost savings, and enrich patient satisfaction.
EHR Talking Points for PA Discussion with Employers
EHR Design and Implementation
- EHRs should be designed with considerations for utilization, functionality and efficiency by PAs and other health professionals. When appropriately designed and implemented for use by all relevant health professionals, EHRs can improve quality, increase patient safety, enhance operational efficiencies, provide cost savings, and increase patient satisfaction.
- PAs should be included as part of the team that provides input into the design, build, testing, implementation, and ongoing management of EHR systems. Without PA participation, key aspects of PA participation might be overlooked. These oversights are more difficult to correct once the system is fully designed and implemented as opposed to during the design phase.
- EHRs need to be adaptable to the specialty, scope of practice, and privileges of individual PAs. The type of EHR access granted, as well as any automatic ordering restrictions, should be able to be altered based on a PA’s specialty.
- The professional work of PAs should be transparent and able to be identified through data captured by EHRs. This data should include patient encounters, as well as measure contribution to care delivery for non-reimbursed services (e.g. computerized order entry, patient care documentation, diagnostic review and follow-up, and patient communications). Care provided by PAs during “incident to” or shared visit billing, and billing under a collaborating physician should be identified as work performed by the PA.
Quality & Safety
- Improving healthcare quality and ensuring patient safety are potential benefits of EHRs. To do this, there needs to be accurate attribution of patients to PAs. EHRs need to ensure that orders and test results are appropriately attributed to the ordering PA. PAs also need to be able to accurately assess their panel of patients for population health management, compliance with quality measures, and self-assessment.
- EHRs should reflect the regulatory requirements of federal, state and facility policy to ensure the maximum utilization of PAs.
- EHRs should ensure that the recognition of a PA’s participation in patient care is not
removed from the EHR when subsequent care is provided by another health professional or if an addendum is added to the medical record by another health professional.
Electronic Health Records and PAs: A White Paper
Integration and inclusion of PAs (physician assistants) in electronic health records (EHRs) is essential to achieve comprehensive care for individuals, better health for populations, and reduced healthcare costs. This can be achieved by addressing the EHR needs of PAs both in the design and development of EHR software, and during the readiness planning and implementation of EHR systems at clinics, hospitals, nursing facilities, health systems, and all healthcare settings.
EHRs should be designed to contribute to transparency and measure the contribution of patient care provided by PAs. Methods of measuring the contribution of services provided by PAs should be incorporated into the functionality of EHRs. This identification of professional work is important for clinical assessment, practice improvement, measuring productivity and care contribution, and management of population health.
EHRs must also be functional and have efficient workflows to gain provider acceptance and promote optimal patient care. Design-inefficiency for PAs and collaborating physicians may inhibit acceptance and adoption of EHRs, lead to noncompliance with regulations and institutional policies, and adversely affect patient care and health promotion.
EHRs and PAs
The electronic health record (EHR) is transforming healthcare with the goals of achieving more coordinated care for individuals and better health for populations. When appropriately designed and implemented, the value of EHRs has been demonstrated to improve quality, increase patient safety, improve operational efficiencies, provide cost savings, and improve patient experience and satisfaction (Healthcare Information and Management Systems Society, 2009).
To achieve these benefits, EHRs must be fully functional and operational for all designated healthcare professionals, including PAs (physician assistants). PAs are integral members of the healthcare team who provide care that would otherwise be delivered by physicians. There are PA-specific EHR needs in the areas of functionality, care attribution, transparency, and regulatory compliance. Currently accounting for about 10 percent of the healthcare provider workforce, the Bureau of Labor and Statistics (2015) projects a 30 percent increase in employment of PAs from 2014 to 2024. Due to the contribution of PAs to the
provision of high-quality healthcare and the need to ensure efficient team practice, EHRs should be designed with specific functionality considerations for PAs. Optimal EHR functionality is essential for quality improvement, enhanced patient outcomes, ensuring accurate medical and legal documentation, compliance, transparency, research, and incentive-based payment programs.
To accomplish these goals, EHR developers must consider the needs of PAs from the inception of software design. EHR vendors have historically focused on physician and nursing end-users when designing systems. Many vendors employ physicians and/or nurses to help either guide development or provide subject matter expertise at the front-end of development. Key PA attributes might be overlooked due to lack of awareness by these particular subject matter experts. Development flaws and oversights are often difficult to correct once the system is fully designed and implemented. The needs of end users of EHRs should be contemplated and reflected in system design and implementation to mitigate safety risks, achieve full functionality, and realize maximum benefits of use (Institute of Medicine [IOM], 2012). PAs should be included as part of the team that is assembled to guide design, build, test, implement, and support EHRs.
Accuracy and Transparency
Authorship attributes the origin or creation of a particular unit of information to a specific individual or entity acting at a particular time. When there are multiple authors or contributors to a document, all signatures should be retained so that each individual’s contribution is unambiguously identified. Some EHR systems allow more than one individual to add text to thesame progress note entry or flow sheet. If the EHR does not have functionality to enable both providers to document and sign, it may be impossible to verify that actual service provider or the amount of work performed by each provider (Integrity of the healthcare Record: Best Practices for EHR Documentation 2013 update).
EHRs should be able to track the contribution of every clinician who provides professional services to patients. Because of “incident to”, shared visit billing and different models of delivering team-based care, the contribution of a PA’s services may be unaccounted by traditional measures such as billing claims, relative value units or volume of services rendered. EHRs should design methods of measuring the contribution of services provided by PAs to ensure transparency in healthcare. This identification of professional work is important for clinical assessment, practice improvement, measuring productivity and care contribution, and management of population health.
Quality and Safety
Ensuring patient safety and healthcare quality is essential to improving individual and population health and reducing healthcare costs. Accurate attribution of patients, treatments, and diagnostic tests to a rendering provider is needed for self-assessment and quality improvement. In addition, to improve patient safety, the Office of the National Coordinator for Health Information Technology (2016) recommends that ordering providers be identified on all test orders and reports, be notified of results, and have result notifications remain in inboxes until addressed. In order to improve patient safety and quality outcomes, EHRs need to ensure that orders and test results are appropriately assigned to the ordering PA.
Resource Utilization and Reimbursement
An essential component of cost-effective care is accurate attribution of costs and the resources expended for treatment to the responsible clinician. Attribution is needed for accurate, actionable data to result in reduced spending and efficient use of resources (Centers for Medicare and Medicaid Services [CMS], 2016). In addition, assignment of responsibility for cost is increasingly important as CMS and private payers reimburse based on quality, episode-based payment models, and cost-savings incentives. In order to achieve accurate reimbursement and promote cost containment measures, it is essential that EHRs:
- attribute costs to the health professional who rendered the service and/or an ordering professional,
- measure contribution to care delivery for non-reimbursed services (e.g. computerized order entry, patient care documentation, diagnostic review and follow-up, and patient communications),
- and, identify care provided by PAs during “incident to” billing, shared visit billing, and billing under a collaborating physician for Medicare, Medicaid, and commercial insurers.
Compliance and Operability
EHRs should be capable of complying with federal, state, and facility policies and regulations. For example, a requirement for a physician co-signature on a specific PA order should be a potential function of an EHR system. However, there should not be an automatic system default that because a physician co-signature is necessary on a particular order that all PA orders require a physician co-signature. Thatmisinterpretation can lead to unintended consequences of unnecessary work, which can undermine provider acceptance of EHRs, increase work and costs, and potentially result in patient harm (Jones et al., 2011). An EHR should also ensure the co-signature of a physician does not override the attribution of services by a PA.
EHR operability and functionality considerations for PAs are particularly important for avoidance of fraud and abuse. The Office of Inspector General (2013) recommends EHR safeguards to avoid fraud, which include user logs and controls to validate claims with rendering provider profiles to avoid submission of false claims by physicians when PAs are involved in shared care but physician participation or supporting documentation is missing. EHRs also need to safeguard against the ability to change the authorship of a document to ensure an accurate medical-legal document and prohibit fraud, and a physician should not have the ability to edit a PA’s note as they would be able to do for a resident or fellow.
PAs are a critically important component to the delivery of efficient, high quality healthcare services. There are PA-specific issues that should be acknowledged to ensure effective EHR functionality, attribution, transparency, and regulatory compliance. Addressing the EHR needs of PAs is important both in the design and development of EHR software, and during the readiness planning and implementation of EHR systems at clinics, hospitals, nursing facilities, health systems, and all healthcare settings. Full integration and inclusion of PAs in EHR systems is essential to achieve comprehensive care for individuals, better health for populations, and reduced healthcare costs.
Contact Sondra DePalma at [email protected] for more information.
Bureau of Labor Statistics. (2015, Dec. 17). Occupational outlook handbook: Physician assistants. Retrieved from https://www.bls.gov/ooh/healthcare/physician-assistants.htm
Healthcare Information and Management Systems Society. (2009). The value of electronic health records. Retrieved from http://www.himssehra.org/docs/ValueEHRs.pdf
Institute of Medicine. (2012). Health IT and patient safety: Building safer systems for better care. Washington, DC: The National Academies Press.
Jones, S. S., Koppel, R., Ridgely, M. S., Palen, T. E., Wu, S., Harrison, M.I. (2011, Aug.) Guide to reducing unintended consequences of electronic health records: AHRQ Publication No. 11-0105-EF. Prepared by RAND Corporation.
Office of Inspector General. (2013, Dec.). Not all recommended fraud safeguards have been implemented in hospital EHR. Retrieved from https://oig.hhs.gov/oei/reports/oei-01-11-00570.pdf
Office of the National Coordinator for Health Information Technology. (2016, Nov.). Safety assurance factors for EHR resilience: Test results reporting and follow-up. Retrieved from https://www.healthit.gov/safer/sites/safer/files/guides/safer_test_results_reporting.pdf