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6 The Influence of the External Environment on Clinician Burnout and Professional Well-Being â[Clinicians] are often forced to make tough decisions that involve their patients, insurance companies, pharmacies, pharmaceutical companies, the hospital, or clinic admin- istrators, among others. Oftentimes, there is no one clear answer as to what the best decision is. The decision-making process can be challenging and anxiety-provoking, espe- cially when a patientâs well-being is at stake. They are often faced with a moral dilemma and have to balance the possi- ble benefits and risks that may result from their decisions.â (Tough Decision, Edi Matsumoto)1 Dramatic changes in the U.S. health care system over the past several decades have affected cliniciansâ professional responsibilities and workplace experiences in profound ways. In this chapter the committee examines economic (or market), regulatory, and social factors in the external environ- ment that affect health care organizations (HCOs) and contribute to work- place stress and greatly diminish cliniciansâ professional well-being. The external environment is the third level of the committeeâs systems frame- work for clinician burnout and professional well-being (see Figure 6-1). As 1 Excerpted from the National Academy of Medicineâs Expressions of Clinician Well-Being: An Art Exhibition. To see the complete work by Edi Matsumoto, visit https://nam.edu/Â expressclinicianwellbeing/#/artwork/220 (accessed January 30, 2019). 167
168 TAKING ACTION AGAINST CLINICIAN BURNOUT described in Chapter 2, the external environment influences the structure and performance of HCOs directly and, through them, the frontline care delivery level. Cliniciansâ experiences of external environmental demands is influenced by HCOsâ interpretations of regulatory and administrative requirements and decisions about work processes. (See Chapter 4 for the work system factors under the control of HCOs that influence clinician burnout and well-being and Chapter 5 for more about HCO actions and decisions affecting the clinical work system and the care team.) This chapter focuses on the available evidence related to the ways that three external environment factors contribute to cliniciansâ workplace stress: (1) structural changes in the U.S. health care industry, including the growth of large, health care corporations; (2) the laws, regulations, and standards for the oversight of U.S. clinicians; and (3) 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 6-1âThe external environment level of the systems model of clinician burnout and professional well-being.
THE INFLUENCE OF THE EXTERNAL ENVIRONMENT 169 values and the clinicianâpatient relationship. The chapter discusses health information technology (IT) in the context of some of the policies asso- ciated 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 clini- cians, and the innovations under development. HEALTH CARE INDUSTRY Efforts to improve the quality of health care and reduce its cost have led to the unprecedented changes that are ongoing in todayâs health care system. These changes, however, are occurring within a highly fragmented health care system that is characterized by a vast array of complex interÂ relationships among those who receive, provide, finance, and regulate care. The many different stakeholders often have divergent interests and ex- pectations, which complicates efforts to improve the system (Altman and Frist, 2015; Moses et al., 2013). Clinicians and the work environment are affected by the shifts toward the industrialization of health care delivery, toward greater accountability and transparency through measurement, and toward new care delivery and payment models. The practice of medicine, once considered a cottage industry practiced by individuals or small partnership groups, started transitioning toward multi-specialty groups and corporations in the 1990s (Maloney, 1998). On- going structural changes in the health care industry, including the horizontal and vertical integration of insurers, hospitals, pharmacies, and physician and dental practices, are leading to an increasing number of clinicians be- ing employed by large corporations. These changes are also bringing about the wider application of industrial-type operational strategies by HCOs designed to deliver care more efficiently, such as greater divisions of labor and reliance on unskilled labor, standardization of roles and tasks, and the creation of corporate managerial structures (Casalino, 2017; Moses et al., 2013; Rastegar, 2004). One analysis estimated that the number of health care administrators increased 3,200 percent between 1975 and 2000, thus, underscoring the nature of the structural changes occurring in the industry (Cantlupe, 2017). Corporate employment can provide various advantages to physicians, such as freedom from the business demands of operating a practice, nego- tiating leverage with health insurers over payment rates, and, potentially, more control over their work schedules (Casalino, 2017). At the same time, the managerial hierarchy in health care corporations can have control over many domains that affect clinicians, including the
170 TAKING ACTION AGAINST CLINICIAN BURNOUT application of clinical algorithms, practice guidelines, standardization of procedures, cost-control measures that affect care directly (such as choice of orthopedic prostheses and implantable cardiac devices), quality improvement programs, and supply of clinical information required by i Ânsurers. (Moses et al., 2013, p. 1957) Care delivery strategies such as standardization, cost controls, and productivity targets can create schisms between individual cliniciansâ values and expectations and those of the organization as well as declines in the cli- niciansâ sense of control, flexibility, and autonomy and a potential erosion of professional values (Casalino, 2017; Moses et al., 2013; Rastegar, 2004). These tensions between HCOs and clinicians can contribute to work stress, job dissatisfaction, and burnout (Gregory and Menser, 2015; Linzer et al., 2017; Rothenberger, 2017). See Chapter 3 for the consequences of burnout and Chapter 4 for details on the work-related sources of clinician burnout. LAWS, REGULATIONS, AND STANDARDS Mirroring the complex organization of the U.S. health systems and the major changes in care delivery and financing, the U.S. regulatory landscape for the oversight of the health professions includes a multitude of ever- changing regulatory and oversight bodies that define and influence many aspects of a clinicianâs responsibilities and actions. Health care laws and regulations are promulgated by federal, state, and local governments and affect institutional providers as well as individual clinicians. Additionally, private organizations supplement the work of governmental regulators by issuing standards, such as those that are used to accredit health professions schools, administer licensing examinations, and certify specialists (Field, 2008). Also, health professional organizations and societies have had a longstanding role in self-regulation (authority over certain legal, economic, and institutional aspects of the profession) (Havighurst, 1983), although the authority of each organization varies greatly (Madara and Burkhart, 2015). The myriad laws and regulations as well as the many accreditation and other professional standards are intended to support the health care system, for example, by engendering public confidence in the competence of physicians through licensure requirements (Field, 2008). However, despite areas of overlap, oversight bodies at times operate without coordination (Field, 2008), which is contributing to growing concerns about the burden of administrative requirements on clinicians (a contributory factor to burn- out; see Chapter 4). Policy makers often fail to assess the impact of new regulations or requirements before they are implemented (Lee et al., 2019a).
THE INFLUENCE OF THE EXTERNAL ENVIRONMENT 171 A 2017 survey of members of a multi-specialty academic faculty in New England found that the average time spent by a physician on administrative duties was nearly 28 percent of the physicianâs work week, and this appears to have increased since 2014. Prior authorizations, specialty recertifications, and compliance regulations related to opioid prescribing were the duties for which required faculty engagement had increased the most over the 3-year study period (Del Carmen et al., 2019). Growing administrative requirements, many of them discussed in this chapter and in Chapters 4 and 7, can interfere with the care experience of patients and âdrain time and moraleâ from clinicians (Berwick et al., 2017, p. E1). In response to the negative effects of administrative burden on patient care and on clinicians, clinician-led efforts have begun to focus attention on the problem. In 2018 six medical professional organizations representing 560,000 physician and medical student members called upon U.S. Congress, the administration, payers, vendors, and other stakeÂ olders h to expand and accelerate efforts to reduce administrative burden. The six organizations issued joint principles calling for the simplification of clini- cal documentation requirements, improved performance measures, and the streamlining or elimination of prior authorization forms. These organiza- tions also encouraged better leveraging of health IT to improve usability and clinical workflows and called for continuous evaluations of regula- tions and administrative tasks on clinicians and patients (AAFP, 2018). In addition to this call to action, the American College of Physiciansâ Patients Before Paperwork initiative is identifying and prioritizing the most burdensome administrative tasks faced by clinicians, developing policy recommendations to address these administrative tasks, and engaging in ongoing outreach and stakeholder engagement efforts with external sources of administrative and regulatory burden (ACP, 2018a). Chapter 5 discusses an approach some HCOs are taking to modify or eliminate administrative rules that contribute little or no value to patient care (Berwick et al., 2017). 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 docu- mentation and coding, quality measurements and reporting, prescription drug monitoring, privacy rules, and prior authorization forms. (Laws and regulations related to electronic health records and other technologies are discussed in Chapter 7.) In the latter part of this section, the committee ad- dresses professional licensure, board certification, and professional liability.
172 TAKING ACTION AGAINST CLINICIAN BURNOUT Health Care Reform and Payment Policies The Patient Protection and Affordable Care Act of 20102 initiated a significant federal interest in value-based health care. The more re- cent Medicare Access and CHIP (Childrenâs Health Insurance Program) ReauthorizaÂion Act of 20153 (MACRA) (in particular, the new payment t options under the MACRA Quality Payment Program [CMS, 2019b]), along with initiatives in the private sector (Health Care Transformational Task Force, 2017) are accelerating the value movement. These initiatives include linking payment to value by using alternative payment models, increasing care integration and coordination to improve population health (i.e., the medical home model), and using information technology to im- prove patient care. A goal is to substantially change incentives to promote the delivery of higher value care by clinicians and HCOs. Figure 6-2 shows eight federal value-based programs that have been implemented over the past decade. Most recently, under MACRA, the U.S. Department of Health and Human Services (HHS) set a goal of having 90 percent of Medicare fee-for-service payments linked to quality or value by 2018 (HHS, 2015). In 2019 MACRA introduced a two-track Quality Pay- ment Program for participating Medicare clinicians. Under the Merit-Based Incentive Payment System, participating clinicians receive performance- based payment adjustments, and under alternative payment models such as accountable care organizations, clinicians have additional incentives to provide high-quality and cost-efficient care (CMS, 2019b). In addition to the payments they receive from participating in federal value-payment programs, HCOs and clinicians are, of course, reimbursed for their services and procedures by multiple commercial insurers and conÂ sumers. Payment structures can vary from fee-for-service to newer value- based models. Each payer has its own set of rules and regulations with Â different levels of complexity (Gottlieb et al., 2018). For example, there is variation in practice requirements (e.g., credentialing); variation in the condi- tions, tests, and treatments that are covered and the associated coding rules (i.e., Current Procedural Terminology [CPT] and the International Classifica- tion of Diseases, Tenth Revision [ICD-10]); variation in the payment-related incentives and penalties employed; and variation in the quality measures required to be reported (see the section on quality reporting below). There are many reports in the literature concerning how the existing fed- eral and commercial payment schemes have created a confusing and onerous environment for clinicians. Managing multiple payment systems with com- plex rules, processes, metrics, and incentives that may frequently change is a 2 Public Law 111-148, 124Â Stat. 119. 3 H.R. 2, Public Law 114-10.
THE INFLUENCE OF THE EXTERNAL ENVIRONMENT 173 FIGURE 6-2â Federal value-based care programs, 2008â2019. SOURCE: CMS, 2019c. source of considerable burden for clinicians (Casalino et al., 2016; Cohen et al., 2018; Wynne, 2016). As private insurance plans continue to follow the Centers for Medicare & Medicaid Servicesâ (CMSâs) 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). One study of clinical hospital pharma- cists found that uncertainty regarding health care reform is a risk factor for burnout (Jones et al., 2017). To the extent that payment policies and requirements are causing sub- stantial administrative burden, financial pressures, or other negative effects on clinicians to the point that they are leaving their practices, the very success of health care reform may be threatened (Dyrbye and Shanafelt, 2011) and create barriers to patient care. For example, third-party reimbursement policies un- der Medicare Part D have been reported to contribute to community pharma- cistsâ financial stress (Gabay, 2017) and the closing of community pharmacies, which may reduce access to care, particularly in rural communities where there may be only one community pharmacy and the pharmacist may be the only local health care provider (Ullrich et al., 2017).
174 TAKING ACTION AGAINST CLINICIAN BURNOUT Medical Records Documentation and Coding Requirements Medical records documentation facilitates several functions, including the recording of pertinent information regarding a patientâs health history, the planning and evaluation of a patientâs treatment, the monitoring of a patientâs health over time, communication among providers involved in the patientâs care, billing, carrying out reviews of usage and quality of care, liability protection, and data collection for research. Myriad federal and state laws and regulations impose specific documentation require- ments on health care providers.4 For example, the Medicare conditions of participation state that â[t]he medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patientâs progress and response to medications and ser- vicesâ 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 per- taining 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 documen- tation 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)(2) Medical Records; Commonwealth of Massachusetts, Division of Health Care Facility Licensure and Certification, Hospital licensure, 105 CMR 130. 5 See 42 CFR Â§ 482.24 (C). 6 See, e.g., 42 CFR Â§ 495.20âMeaningful use objectives and measures for eligible profes- sionals, eligible hospitals, and critical access hospitals before 2015. 7 See 42 CFR Â§ 495.24âStage 3 meaningful use objectives and measures for eligible profes- sionals, eligible hospitals, and critical access hospitals for 2019 and subsequent years. 8 See, e.g., Section 13: Medical Records, Telemedicine Standards of Practice, Board of L Â icensure in Medicine and Board of Osteopathic Licensure, Maine Department of Profes- sional and Financial Regulation. (âA licensee who uses telemedicine in providing health care shall ensure that complete, accurate and timely medical records are maintained for the patient when appropriate, including all patient-related electronic communications, records of past care, physician-patient communications, laboratory and test results, evaluations and consul- tations, prescriptions, and instructions obtained or produced in connection with the use of t Â elemedicine technologies. The licensee shall note in the patientâs record when telemedicine is used to provide diagnosis and treatment.â)
THE INFLUENCE OF THE EXTERNAL ENVIRONMENT 175 public health data, and disease tracking and trending. Moreover, hospital bylaws and rules and regulations typically address the content of medical records9 and impose their own sets of requirements, based on organiza- tional goals, values, and the interpretation of external expectations. These multiple sources of clinical documentation requirements lead to duplicative and inconsistent requirements (AHA, 2017) that are burdensome and time consuming. The American Hospital Association reports that hospitals are required to comply with 341 mandatory regulatory requirements, at an estimated annual cost of $7.6 million per community hospital, on aver- age. Larger hospitals can spend up to an estimated $19 million annually. Fulfilling these demands requires 59 full-time staff per hospital, more than one-fourth of which are doctors or nurses who could otherwise be provid- ing direct patient care (AHA, 2017). To fulfill the requirements, short cuts, such as use of copy-and-paste functions and check boxes, are commonly employed, but they may result in an increased risk of poor-quality notes, contradictions in the history, and inadequate documentation (Dimick, 2008). Another increasingly popular strategy to help clinicians complete documentation is the use of medical scribes. (Chapters 5 and 7 discuss the evidence associated with the use of scribes.) Excessive paperwork and doc- umentation is also a stressor for other professions. For example, Schommer and colleagues (2018) identified higher levels of reported time stress among community pharmacists than among hospital pharmacists; doing excessive paperwork or documentation (i.e., third-party work) was found to be one of seven items that may contribute to time stress (Schommer et al., 2018). Clinical Documentation Redesign As a result of the many reports that have examined the burden as- sociated with clinical documentation and other clerical tasks (Arndt et al., 2017; Baumann et al., 2018; Shanafelt et al., 2016; Sinsky et al., 2016; Tai-Seale et al., 2017) (see Chapter 4 for details), there have been multiple calls for a significant redesign of clinical documentation (ACP, 2018b; Haas et al., 2019; Ommaya et al., 2018). Federal actions to reduce the effort and time required to record health information include the development of a draft Strategy on Reducing Regu- latory and Administrative Burden Relating to the Use of Health IT and EHR (ONC, 2018) released by the HHS Office of the National Coordi- nator for Health Information Technology (ONC) in 2018, as directed by 9 The Joint Commission Standard, Medical Staff (MS); MS.01.01.01, EP 16 mandates that requirements for completing and documenting medical histories and physical exams in accordance with state law and hospital policy must be included in the medical staff bylaws.
176 TAKING ACTION AGAINST CLINICIAN BURNOUT U.S. Congress under the 21st Century Cures Act.10 In response to ONCâs proposed strategy, the American Medical Informatics Association (AMIA) called for HHS to adopt a long-term electronic health record (EHR) strat- egy that uses informatics tools and methodologies to gather information from care documentation and apply it to clinical decision support and improving performance (Fridsma, 2019). In AMIAâs view, efforts to im- prove clinical documentation and reduce clinician burden should focus on clinically purposeful documentation and not just on reduced documentation (Fridsma, 2019). In addition, CMSâs Patients over Paperwork initiative, launched in 2017, has made a number of changes in an attempt to simplify Medicare documentation requirements in order to reduce the amount of time clini- cians spend on claims documentation (CMS, 2019a). In June 2019, CMS announced that it is actively soliciting public feedback to shape Patients over Paperworkâs next steps and future progress in tackling unnecessary clinician burden (CMS, 2019a). 10 Public Law 114-255.
THE INFLUENCE OF THE EXTERNAL ENVIRONMENT 177 Connections Heal Patients and Clinicians a As many clinicians battle with endlessly long hours, admin- istrative burden, low sense of accomplishment, and difficult workâlife balance, it is important for clinicians to take a step back and have a time for reflection. With continued stress and exhaustion, clinicians may lose sight of rewarding and inspir- ing moments in their patient care.... a Excerpted from the National Academy of Medicineâs Expressions of Clinician Well- Being: An Art Exhibition. To see the complete work by Sung Min Ma, visit https://nam.edu/ expressclinicianwellbeing/#/artwork/127 (accessed January 30, 2019). SOURCE: Reflection, Sung Min Ma. Quality Measurement and Reporting Documenting and reporting quality measures is of paramount impor- tance to improving health care. Two Institute of Medicine reports, To Err Is Human: Building a Safer Health System (IOM, 2000) and Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001), powerfully brought the publicâs attention to significant gaps in health care quality and safety and to the importance of measuring system performance. Since then a growing number of employers, payers, and regulators have required the reporting of quality and safety information (e.g., Healthcare Effectiveness Data and Information SetÂ®11 clinical measures, Consumer 11 HealthcareEffectiveness Data and Information Set (HEDISÂ®) is a registered trademark of the National Committee for Quality Assurance.
178 TAKING ACTION AGAINST CLINICIAN BURNOUT Assessment of Healthcare Providers and SystemsÂ®12 patient experience measures, and Leapfrog hospital survey data) from health plans, hospitals, and health systems. At the same time, published comparative score cards and rankings (e.g., Hospital Compare [CMS, 2000], Quality CompassÂ®13) based on these performance data have emerged as key drivers for improved accountability, transparency, and increased value in health care. Value-based payment models require measures of quality, patient ex- perience, and efficiency, which is contributing to a proliferation of perfor- mance measures and reporting requirements, with a commensurate increase in the burden on clinicians who are recording and collecting the data (NQF, 2019). Although many of the performance measures provide useful information, there are many that do not (because they are duplicative, not clinically relevant, have poor methodological design, etc.) and are thus not effective in improving the performance of the health system (Berwick, 2016; IOM, 2015; MacLean et al., 2018). The current mandatory measurement requirements, which include measures that are not important to patient health (Berwick, 2016; Dunlap et al., 2016; IOM, 2015; Panzer et al., 2013; Safran and Higgins, 2019), contribute to the perception that current quality measures detract from meaningful clinical activity and deprofessionalize the clinician (Khullar et al., 2018; Pronovost et al., 2018), as well as adding a substantial burden to the workload of clinicians (Casalino et al., 2016; Sinsky et al., 2016) (see Chapter 4), even with the use of current health information technology (Cohen et al., 2018). Multi-stakeholder efforts to decrease the burden associated with quality measurement are ongoing. For example, the Measure Applications Partner- ship (MAP), convened by the National Quality Forum (NQF), guides HHS on the selection of performance measures for federal health programs. In its 2017 guidance (NQF, 2017), MAP called for a reduction in the number of measures in federal programs as well as better feedback from frontline clinicians to ensure that measures are driving improvement and not causing negative consequences (e.g., burnout) on clinicians. In addition, the Core Quality Measure Collaborative (CQMC), involving Americaâs Health Insur- ance 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.Â In developing core sets of performance measures, CQMC aims to âreduce the burden of measure- ment 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 (CAHPSÂ®) is a registered trademark of the Agency for Healthcare Research and Quality. 13 Quality CompassÂ® is a registered trademark of the National Committee for Quality Assurance.
THE INFLUENCE OF THE EXTERNAL ENVIRONMENT 179 payersâ (NQF, 2019). CQMC indicates it is monitoring the use of these measures and will use lessons learned to modify them and minimize their negative consequences (CMS, 2017). Prescription Drug Monitoring Program Requirements Currently, 49 states, the District of Columbia, and one U.S. territory (Guam) have authorized a prescription drug-monitoring program (PDMP). PDMPs are state-operated data repositories that collect, monitor, and ana- lyze electronically transmitted patient-specific prescribing and dispensing data submitted by pharmacies and dispensing practitioners with the goal of reducing prescription drug abuse and diversion. When prescribers or pharmacists query the database for a patientâs prescription history, they can see prescription information regarding the dose, supply, and prescriber of scheduled drugs the patient has filled. Clinicians can use this informa- tion to inform their prescribing decisions, avoid polypharmacy, and refrain from supplying opioids to patients exhibiting drug-seeking behavior. The circumstances under which a clinician is required to access the database, however, vary from state to state. As of January 2019, at least 43 of the 49 states with PDMPs (plus Guam) now legally mandate prescribersâand 20 mandate pharmacistsâto query the system prior to writing or dispensing a prescription for controlled substances with recognized potential for abuse or dependence (PDMP TTAC, 2019). While this policy is well intended and serves the need to curb prescription drug abuse, requiring clinicians across care settings to query PDMPs can be burdensome (Haffajee et al., 2015). In querying PDMPs, prescribers have experienced difficulty in obtaining logins, encountered system downtime, and noted that information is not integrated into clini- cal workflow with often incomplete data (Haffajee et al., 2015). According to a 2018 JAMA Surgery study, clinicians without PDMP databases built directly into their EHR systems (i.e., one-click access) spend an average of 13 minutes per patient to complete PDMP queries, opioid risk calculator processes, and required institutional informed consent processes (Stucke et al., 2018). To increase the use of PDMPs, the Substance Abuse and Mental Health Services Administration funded projects in nine states from fiscal years 2012 to 2016 through its PDMP Electronic Health Records Integration and Interoperability Expansion (PEHRIIE) program (CDC, 2017). Ensuring that prescribers have one-click access to state PDMP data is one strategy to reduce administrative burden on clinicians by eliminating the need for prescribers to manually log into PDMPâs website separately. EHR integra- tion of PMDP data is becoming increasingly common across the country (Monica, 2018a,b) and will likely accelerate with the emergence of new
180 TAKING ACTION AGAINST CLINICIAN BURNOUT private-sector initiatives facilitating clinician access to prescription drug information at the point of care (DrFirst, 2019). CMS has also taken action to reduce the burden associated with P Â DMPs. In 2018 CMS called on state Medicaid programs to improve EHR integration of PDMP data to enhance appropriate and safe prescribing, reduce provider burden, and allow HCOs to more easily track patient information related to opioid use (Hill, 2018). In its guidance to states, CMS stated, This integration removes the requirement for providers to log in to a sepa- rate system, manage a separate login and disrupt their workflow to query the PDMP. Single sign-on interoperability between EHR and PDMP, such that PDMP results are displayed when the EHR indicates a controlled sub- stance is prescribed, could be supported, as an example. (Hill, 2018, p. 2) In addition, under Medicare Part D, CMS has implemented a voluntary prescription drug benefit that makes e-prescribing optional for physicians and pharmacies but requires drug plans that participate in the prescription benefit to support electronic prescribing (CMS, 2014). Maintaining Privacy and Security Compliance Federal and state laws and regulations impose obligations on HCOs and clinicians to maintain the privacy and security of health information. For example, the goal of the Health Insurance Portability and Accountabil- ity Act (HIPAA) privacy standards is to protect the integrity, confidentiality, and availability of health data. Similarly, the purpose of the HIPAA Security Rule is to establish national standards for the protection of electronic pro- tected health information (PHI). The steps required by clinicians to comply with federal and state privacy and security laws and regulations concern- ing health information along with related organizational policies and pro- cedures add to the administrative burden on clinicians. For example, the HIPAA Privacy Rule requires that an authorization contain either an expi- ration date or an expiration event that relates to the patient or the purpose of the use or disclosure.14 Some HCOs require patients to execute written authorization for the use and disclosure of PHI on an annual basis. Such a requirement results in clinicians searching the EHR to find the most recent authorization, making sure that it has been signed within the past year and, if not, obtaining a new form from the patient. Additionally, two com- mentators have noted that misapplications of the HIPAA requirements have unnecessarily resulted in restricting the exchange of clinical information 14 45 CFR Â§ 164.508(c)(1)(v).
THE INFLUENCE OF THE EXTERNAL ENVIRONMENT 181 between treating clinicians and have led to rules against posting patientsâ names in clinical areas to facilitate finding or identifying the patient and also rules against family members or loved ones reviewing medical records and clinical information even with the patientâs permission (Berwick and Gaines, 2018). Another example of HCOsâ influence on the implementation of privacy and security laws and regulations and the effects on clinician burden relates to patient communications, including e-mail, text messaging, or Web-based messaging platforms, all of which are subject to the HIPAA privacy and security standards (HHS, 2019; Liederman et al., 2005). In order to comply with the HIPAA security standards, access to a clinicianâs e-mail and the HCOâs EHR or other Web-based messaging platforms must be password protected. The HIPAA security standards require covered entities to have procedures for creating, changing, and safeguarding passwords.15 In imple- menting such procedures, HCOs typically use stringent password manage- ment requirements (e.g., number of characters, symbols, capitalization, and frequency of change) that clinicians must meet. Dealing with user logon and authentication procedures can be time consuming. For example, in one study of family medicine physicians (n = 142), clinicians were found to have spent nearly as much time on system security as on reading or editing the problem list each day (Arndt et al., 2017). Challenges are amplified for clinicians who use more than one EHR and communication platform, as each requires its own password and software (Gellert et al., 2017; Liu et al., 2019; Luxton et al., 2012). Prior Authorization Process Payers often require clinicians to obtain prior authorization for medica- tions, other forms of treatment, diagnostic procedures, and referrals. The intent of prior authorization is to deter patients from getting unnecessary medical care and to direct prescribers to less costly treatment options where appropriate (and thus reduce the cost of care); however, these require- ments can also create hassles for patients and add to cliniciansâ burden ( ÂJacobson and Neuman, 2018). Different prior authorization rules by dif- ferent payers require inconsistent workflow processes and the submission Â of additional information through manual processes (eHealth Initiative, 2019). Pre-authorization processes, which have to be completed annually even for medications for chronic conditions, are resource-intensive and pose barriers to providing optimal patient care (Brown and Brown, 2018; Del Carmen et al., 2019). In a recent study of physicians at an academic medical center, pre-authorization was the most onerous administrative task 15 45 CFR Â§ 164.308 (a)(5)(ii)(D).
182 TAKING ACTION AGAINST CLINICIAN BURNOUT (Rao et al., 2017). Similarly, a national study of community pharmacists found that prior authorization was a top concern among pharmacists with Medicare Part D, with pharmacists reporting that they spent the most time on prior authorization, followed by reimbursement and formulary issues (Spooner et al., 2017). Among the advocacy initiatives to reform prior authorization and re- duce the burden on clinicians and patients is a consensus statement from the American Medical Association (AMA), Americaâs Health Insurance Plans, and other stakeholder organizations (AHA et al., 2018). These stakeÂ olders h identified five areas for improving the prior authorization process: the use of criteria for the selective application of prior authorization require- ments; 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. At the federal level, more than 100 members of U.S. Congress sent a letter to the CMS administrator in 2018 expressing concern about Medicare Advantage plansâ use of prior authorization and the associated administrative burden placed on clinicians (Roe et al., 2018). They asked CMS to collect data on the scope of prior authorization practices, prepare a report describ- ing CMS oversight of pre-authorization policies, and engage stakeholders to improve the prior authorization process for patients and clinicians. Professional Licensure Health care professionals in the various disciplines are required to be licensed and must meet certain standards to maintain their licenses. Licens- ing occurs at the state level, and the requirements vary from state to state. Clinicians practicing in multiple states and those using telehealth technolo- gies have additional requirements (FSMB, 2019a). For example, telehealth and telepharmacy require appropriate licensure in all of the jurisdictions where a clinicianâs patients receive care, resulting in clinicians needing to meet yearly or every-other-year licensure requirements in multiple states. Although licensure requirements vary, common requirements include com- pleting medical licensure applications and engaging in continuing medical education, including mandated programs in drug prescribing, child abuse, pain management, and other topics specified by state laws, and maintain- ing an active physician drug monitoring program profile (to detect overÂ prescribing of controlled drugs). Recent efforts to streamline licensing have attempted to expedite medical licensure applications for multistate practice (FSMB, 2014; Interstate Medical Licensure Compact, 2019) and simplify physician licensure applications across multiple states with the use of a
THE INFLUENCE OF THE EXTERNAL ENVIRONMENT 183 Web-based uniform application (FSMB, 2019b). There are similar efforts in place to streamline the nursing licensure process (NCSBN, 2019). The National Association of Boards of Pharmacy adopted an online state license transfer process in 2018 (NABP, 2019). The requirements of each individual state must also be met. State Licensing Board Questions on Mental Health Status Applicants for state licensure in a variety of health professions typi- cally are required to answer questions relating to their physical and mental health status, including any substance use disorders, in both initial and renewal applications. Such questions reflect a responsibility among state medical boards to ensure clinicians are not impaired and that they can meet their statutory duty to promote patient safety. Unfortunately, many medical and nursing license application questionnaires include overly intrusive per- sonal health questions that can be a barrier to clinicians seeking treatment for treatable illnesses (Dyrbye et al., 2017; Halter et al., 2019). While this issue affects a number of licensed health care professionals, state medical licensing board questions relating to the mental health status of physicians have received the most attention in the literature. 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 physiciansâ mental health that were inconsistent with the AMA, the American Psychiatric Association (APA), and the Federation of State Medical Boards (FSMB) policies and recommendations (Dyrbye et al., 2017). A 2017 analysis of state medical board applications for physi- cians seeking first-time licensure found that 84 percent asked about mental health conditions and 92 percent asked about substance use. Of the states that did ask about mental health, only 53 percent limited those questions to conditions that cause functional impairment, and 86 percent included questions about past mental health conditions (Gold et al., 2017). In nurs- ing, Halter and colleagues (2019) report that 30 nurse licensing boards ask questions about mental illness on their applications, 22 of which ask questions that focus on specific diagnoses, examine historical data in the absence of current impairment, or require the applicant to predict future impairment (Halter et al., 2019). There is also some evidence that these requirements discourage honest disclosure and also inhibit treatment seeking among physicians who are struggling with mental health issues. In a survey of 5,829 U.S. physicians, physicians who worked in a state that had overly broad questions on mental health were found to be 20 percent more likely to be reluctant to seek formal care for a mental health condition because of concerns about repercussions to their medical licensure (Dyrbye et al., 2017). A survey of
184 TAKING ACTION AGAINST CLINICIAN BURNOUT female physicians (n = 2,106) found that only 6 percent of physicians with a mental health diagnosis or who had sought mental health treatment re- ported it to their state licensing board (Gold et al., 2016). 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 Ameri- cans with Disabilities Act (ADA) of 1990 (Halter et al., 2019; Polfliet, 2008; Schroeder et al., 2009). Protection of the public from impaired proÂ Â fessionals is a critical function of state licensing boards for medicine, den- tistry, pharmacists, nursing, lawyers, and other regulated professions. This public safety function, however, is in tension with another important public policy objective of avoiding discrimination against persons with disabilities. These competing societal goals have come into conflict with respect to the content of application questions for certain professional licensing boards, and this has led to litigation in both the medical and the legal professions under Title II of the ADA. Title II provides that âno qualified individual with a disability shall, by reason of such disability, be excluded from par- ticipation in or be denied the benefits of the services, programs, or activities of a public entity, or be subjected to discrimination by any such entity.â16 Title II of the ADA further requires state and local government agencies to operate programs so that they are âreadily accessible to and usable by individuals with disabilities.â17 Certain judicial rulings have held that licensing boards are subject to Title II of the ADA because they are empowered by state governments to provide benefits, services, and programs.18 For example, in Medical Society of New Jersey v. Jacobs et al.,19 the New Jersey State Board of Medical Examiners sought information about an applicantâs status as a person with a disability instead of focusing on any behavioral manifestations of dis- abilities that might impair the individualâs ability to practice medicine. The U.S. District Court for the District of New Jersey examined the licensing boardâs inquiry, âHave you ever suffered or been treated for any mental illness or psychiatric problem?â and concluded that questions regarding applicantsâ diagnosis of and treatment for psychiatric illness or condition are unnecessary, where the medical examiners could âformulate a set of effective questions that screen out applicants based only on their behavior and capabilities.â20 Since the Jacobs case, several federal district courts 16 42 U.S.C. Â§ 12132 (Title II) (1994). 17 42 U.S.C. Â§ 12148(a)(1) (1994). 18 See, e.g., Theriault v. Flynn, 162 F.3d 46 (1st Cir., 1998); Burke v. State Bar of Cal., No. C 06-06950 WHA, 2007 WL 39397 (N.D. Cal., Jan. 4, 2007). 19 See Medical Society of New Jersey v. Jacobs et al., 1993 WL 413016 (D.N.J., 1993). 20 Id. (section 7).
THE INFLUENCE OF THE EXTERNAL ENVIRONMENT 185 have ruled on mental health inquiries by state licensing boards.21 Although many of these cases involved questions relating to state bar applications,22 the common issue with medical licensure is the balance of an applicantâs right to privacy with the protection of the public. The FSMB and the APA have noted that a history of mental illness or substance use does not reliably predict a future risk to the public (APA, 1984, 2018; FSMB, 2018). 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 treat- ment seeking (FSMB, 2018). Several recommendations address the necessity of including questions about the mental health of physicians on applica- tions for medical licensure or renewal as well as addressing the appropriate phrasing of such questions, including focusing only on current impairment 21 See Hason v. Medical Board of California et al., 279 F.3d 1167, 1168 (9th Cir. 2002) (Following denial of an application for medical license on the basis of mental illness, rather than on actual functional impairment, the physician filed a pro se complaint in federal dis- trict court alleging discrimination based on his disability in violation of his rights under the U.S. Constitution and Title II of the ADA, which was dismissed. The Ninth Circuit Court of A Â ppeals ruled that the lower court erred in its interpretation of Title II of the ADA, noting that â[t]he act of licensing involves the Medical Board (i.e., a âpublic agencyâ) providing a license (i.e., âproviding a serviceâ) to an applicant for a medical licenseâ and thus falls within the purview of the Act.). 22 See, e.g., Bartlett v. New York State Board of Bar Examiners, 226 F.3d 69 (2d Cir. 2000) (The Board denied an applicantâs request for testing accommodations, such as extended time and alternative ways to answer questions. The U.S. Court of Appeals for the Second Circuit concluded that if the applicant had a disability, then she was entitled to the requested accom- modations because the Board was subject to Title II of the ADA. On remand, the U.S. District Court for the Southern District of New York found the Boardâs failure to accommodate the plaintiffâs reading impairment was a substantial factor contributing to her failure to pass the bar and that she was entitled to reasonable accommodations when taking the bar exam.); Clark v. Virginia Bd. of Bar Examiners, 880 F. Supp. 430, 436-440 (E.D. Va. 1995) (the U.S. District Court for the Eastern District of Virginia found a question reading, âHave you, within the past five years, been treated or counseled for any mental, emotional or nervous disorders?â to be overly broad, unproven in its necessity, and potentially discriminatory; the Clark court determined that only questions concerning an applicantâs conduct are permissible in assessing the applicantâs current level of competence. Additionally, the Clark court held that even if open-ended questions are limited in time, there was no evidence of a correlation between past psychiatric treatment and current functional impairment. Although it invalidated the bar examinersâ question, the Clark court indicated that the ADA would permit some form of mental health inquiry); Ellen S. v. Florida Board of Bar Examiners, 859 F. Supp. 1489, 1493-94 (S.D. Fla. 1994) (Applicant for admission to the bar sued the Florida Board of Bar Examiners claiming that application questions pertaining to an emotional disorder violated the Title II of the ADA, and the U.S. District Court for the Southern District of Florida held that a defendant need not have knowledge of the plaintiffâs disability in order to violate Title II of the ADA and that questioning the applicant as to whether she had ever sought treatment for a nervous, mental, or emotional disorder or had been diagnosed as having such a condition violated the Act.).
186 TAKING ACTION AGAINST CLINICIAN BURNOUT when state medical boards decide to include these types of questions. The FSMB also encouraged state medical boards âto advance a positive cultural change that reduces the stigma among and about physicians seeking treat- ment for mental, behavioral, physical or other medical needs of their ownâ (FSMB, 2018, p. 2). Similarly, in 2018, the AMA confirmed its stance that physicians should be able to seek the care they need for burnout, anxiety, depression, and substance-related disorders without fear of punitive treatment, discover- ability in malpractice litigation, or licensure and career restrictions (AMA, 2018). 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), North Carolina (Ellis, 2016), Ohio (Ohio Academy of Family Physicians, 2016), and Washington (Fordham, 2018). Board Certification Certification boards have the goal of ensuring the competence of physi- cians and other clinicians completing postgraduate specialty training and throughout their careers (Baron, 2015). In medicine, board certification is a process whereby professional peers set standards for designation as âboard-certified specialistsâ by 1 of the 24 boards of the American Board of Medical Specialties. Board certification requirements include completion of an accredited residency or fellowship program, maintaining a current and unqualified license to practice, and successfully passing a secure ex- amination of knowledge specific to that specialty. Certification has evolved from an initial, one-time event to a program of ongoing education and assessment (recertification) to help physicians stay current with medical knowledge and skills. The Board of Pharmacy Specialties addresses similar issues in pharmacy. Recertification programs, known as âmaintenance of certificationâ (MOC) or, more recently, as âcontinuing certificationâ programs (Vision for the Future Commission, 2019), have been a source of dissatisfaction among physicians. Physicians have strong concerns over the burden, cost, and relevance of MOC programs (Cook et al., 2016; Del Carmen et al., 2019; Teirstein and Topol, 2015; Vision for the Future Commission, 2019). Meeting MOC requirements adds a substantial burden that is typically handled after work, contributing to stress and difficulties with workâlife balance. A survey involving national cross-specialty random sample of licensed U.S. physicians found no association between attitudes toward MOC and burnout (Cook et al., 2016). In 2018 an independent commis- sion (Vision for the Future Commission) was formed to address key issues related to continuing certification programs, and it recently issued its final
THE INFLUENCE OF THE EXTERNAL ENVIRONMENT 187 report with conclusions and recommendations to enhance these programs (Vision for the Future Commission, 2019). 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. Professional liability policies are a response to a litigious society. A 2004 study found widespread discontent among physicians practicing in high-liability environments (Mello et al., 2004). As discussed in Chapter 3, malpractice lawsuits are common (Mello et al., 2004) and are associated with increased stress (Jones et al., 1988) and risk of burnout as well as personal consequences for physicians (Balch and Shanafelt, 2011). The stressors involved in being named in a medical malpractice action may be heightened if the use of emerging technology is involved, particularly given the uncertainty of how current theories of legal liability will apply to claims involving new technology, such as an artifi- cial intelligence (AI) diagnostic tool. Traditionally, medical malpractice is based on negligence, which is defined as any act or omission by a clinician during the treatment of a patient that deviates from the accepted norms of practice and causes injury to the patient. The standard of care in medical malpractice actions, usually a national or community-based standard relat- ing to what is customary practice among physicians in the same specialty in similar settings, generally is established through expert witness testimony.23 In contrast, if a medical device or piece of equipment is responsible for the patientâs injury, then the principles of product liability apply, with its strict liability standard for manufacturing defects, design defects, and failure to warn of such defects. As discussed in Chapter 7, the use of AI tools that are reliable and embedded smoothly in the workflow may help reduce the stress of practice, but they may also place new demands on clinicians. As the use of emerging 23 Jurisdictions differ as to the expected standard of care in a medical malpractice action. The national standard of care requires a doctor to use the degree of skill and care of a reason- ably competent practitioner in his field under same or similar circumstances. The community- based or locality standard requires a physician to have the reasonable caliber of skill and knowledge that is generally possessed by surgeons and physicians in the locality where he or she practices. The respectable minority rule provides that where the physician did not follow the same course of therapy that other doctors would have followed, he can show that his course is accepted by a respectable minority of practitioners. Given the implementation of national standards for medical education and the universal availability of online guidance and evidence, there has been increasing support for a shift to a national standard of care. See Lewis et al. (2007).
188 TAKING ACTION AGAINST CLINICIAN BURNOUT technologies becomes more common, the standard of care in medical mal- practice actions likely will change because certain technologies, such as an AI-based diagnostic tool, may supplant rather than support a clinicianâs professional judgment or function. In determining legal liability, it is pres- ently unclear whether the use of new technologies in patient care that re- sults in injury to a patient will be evaluated under the traditional negligence standard applied in medical malpractice claims or by the product liability doctrine (Bennett and Habte, 2018). 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. Moreover, establishing whether the clinician who employed the AI diagnostic tool or the health IT vendor or the developer is at fault in the event of harm to a patient and then determinÂngi the degrees of comparative negligence among the three will be complicated, given the myriad functionalities and the blurring of boundaries between Â the tasks that are performed by the clinician and the extent to which the AI diagnostic tool is substituting for a clinicianâs professional judgment or function. As AI algorithms improve and clinicians increasingly use this technology for diagnosis and decision making, the traditional malpractice standard of negligence may become more difficult to apply. Not only do lawsuits add economic burden for organizations and clini- cians, but the fear of malpractice can led to lower quality care (Forster et al., 2002). Medical malpractice reform is back on the federal policy agenda, but there is little available evidence that currently proposed medical liability reforms will be effective, with the possible exception of safe harbors and administrative compensation (Mello et al., 2017). Societal Values and the ClinicianâPatient Relationship Over the past several decades, societal values and norms have been shift- ing away from the traditional paternalistic model of health care (âÂ octor D knows bestâ) (Bhopal, 2015; Kilbride and Joffe, 2018) toward a more patient-centered model (Gusmano et al., 2019; Weil, 2019). Currently, this shift places value on a more therapeutic and balanced relationship between clinicians and patients, shared decision making (Montori, 2019; Montori et al., 2019), and a more collaborative care experience. Technology and the Internet are allowing wider access to information about health condi- tions, treatments, quality, safety, and costs, which benefits patients wanting greater participation in the health care they receive (Gusmano et al., 2019). At the same time, some of these same societal changes seem to be contributing to the erosion of patientsâ trust in clinicians and the health care system (Blendon et al., 2014; Lee et al., 2019b; Levey, 2015; Lynch, 2018). Factors reported to be undermining public trust in clinicians and the
THE INFLUENCE OF THE EXTERNAL ENVIRONMENT 189 health care system include the growth in the variety of information sources, perceptions that health care is a business like any other, health care ad- vances and changes to patient care recommendations, quality problems and medical errors, and cost-containment strategies (Lynch, 2018). The 2018 American Board of Internal Medicine Foundation Forum on [Re]Building Trust elaborates the role of trust among and between various stakeholders, including patients, clinicians, health care delivery organizations, payers, and regulators (Lynch, 2018). While several strategies exist to improve the trust between clinicians and patients (Lee et al., 2019b), the committeeâs review of the literature suggests that more needs to be known about the various system factors in- fluencing the clinicianâpatient relationship, such as federal policies, market Â forces, new technologies, health information on the Internet, and orga- nizational policies and practices. A systems approach to supporting and strengthening the clinicianâpatient relationship would focus on the design and implementation of policies, rules, and management actions that demon- strate a commitment to patient values and preferences and at the same time support and sustain the professional well-being of clinicians. As articulated in the committeeâs conceptual framework, this process relies on using feed- back, learning, and improvement principles (see Figure 2-1). The clinician information available on health care rating websites is but one example of an opportunity to balance what consumers value (accurate information to inform health care choices) and what clinicians value (an accurate assessment of the care they provide). As discussed in the beginning of the chapter, the structural organization of the health care industry is shifting, giving HCO administrators greater control over the practices, policies, and procedures governing many aspects of frontline care delivery, while relying on cliniciansâ professional ethics to go above and beyond requirements if patient well-being demands it (Ofri, 2019). There is concern that health care rating websites targeting patients are not accurately reflecting these structural changes in care delivery. That is, health care rating websites report information on aspects of care that are out of the direct control of clinicians (Burn et al., 2018; Lester et al., 2019), such as office staff friendliness, wait times, and ease of parking. In a study of community pharmacy ratings, for example, wait time was most frequently associated with a low rating, and friendliness and helpfulness of staff was most frequently associated with a high rating (Lester et al., 2019). If clini- cian assessments include factors attributable to the HCO and not to the individual clinician or direct patient encounter, patients may not be getting an accurate view of the patient experiences with the individual clinicians, in which case the information is not useful. Because these assessments can have adverse effects on a clinicianâs professional reputation, patient recruit- ment, and revenue, they are an important source of clinician stress. These
190 TAKING ACTION AGAINST CLINICIAN BURNOUT implications for patients and clinicians suggest that taking a systems look at how clinician assessment approaches may be influencing the clinicianâ patient interactions in various ways is warranted. KEY FINDINGS An array of factors within the external health care environment per- petuate the complex landscape of legal, regulatory, standards requirements, and expectations that influence the everyday work of clinicians. While there is little published research that examines how compliance with these requirements directly affects clinicians, it is reasonable to conclude that the combination of the additional clinical workload, the disruptions to workflow, and the time and stress associated with fulfilling the requirements described in this chapter diverts clinician attention away from providing patient care and may contribute to clinician burnout. A better balance between important HCO and societal goals and maintaining clinician well- being is needed. A number of stakeholders have called for reforming these evolving regulations and (at times) redundant and conflicting requirements and expectations. While some efforts to simplify federal regulations have been initiated, it is too early to know if these changes will reduce the burden on clinicians in a meaningful way. What is clear is that further coordinated efforts from a variety of stakeholders are needed to address the issue and to help optimize clinician professional well-being and prevent and mitigate burnout. REFERENCES AAFP (American Academy of Family Physicians), American Academy of Pediatrics, American College of Obstetricians and Gynecologists, American College of Physicians, American Osteopathic Association, and American Psychiatric Association. 2018. Joint principles on reducing administrative burden in healthcare. https://www.acponline.org/acp_policy/ statements/joint_principles_administrative_burden_2018.pdf (accessed July 20, 2019). ACP (American College of Physicians). 2018a. Patients Before Paperwork initiative. P Â hiladelphia, PA: American College of Physicians. https://www.acponline.org/system/files/ documents/advocacy/where_we_stand/patients_before_paperwork/two-pager-Âhandout- pb4p-2018-updated.pdf (accessed February 9, 2019). ACP. 2018b. Physician well-being and professional satisfaction. https://www.acponline.org/ practice-resources/physician-well-being-and-professional-satisfaction (accessed July 3, 2018). AHA (American Hospital Association). 2017. Regulatory overload: Assessing the regulatory burden on health systems, hospitals, and post-acute care providers. Chicago, IL: Ameri- can Hospital Association.
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