Erosion of administrative support in dermatology

By Emily Margosian, Assistant Editor, November 1, 2023

A successful dermatology office is characterized not only by quality patient care, but also efficient administrative practices. However, current data indicate that the administrative burden placed on physicians and their staff is growing. According to the 2023 Medical Economics Physician Report, administrative burden was identified as the top challenge faced by physicians in their practices — a ranking it has maintained annually since 2020.

Additionally, staffing shortages following the COVID-19 pandemic have produced a new thorn for overburdened practices. “I think there’s been a new focus on how we can exploit technology as possible solutions to the post-COVID reality that we will not have the staff that we had before the pandemic,” said Laura Houk, MD, FAAD, member of the AAD Health IT Committee.

This month, DermWorld examines the factors that have contributed to increased administrative burden and reduced support in dermatology, and what resources are available to help fill the gap.

Current landscape

“The top administrative burdens have remained constant for the past several years as reported by dermatologists through Academy surveys and other anecdotal evidence gathered from inquiries received by the practice management team,” said Faiza Wasif, MPH, the Academy’s associate director of practice management. “Electronic health record (EHR) documentation, prior authorizations or insurance interference of treatment, and Merit-based Incentive Payment System (MIPS) requirements top the list.”

According to research and physician testimony, these administrative tasks not only disrupt dermatologist work-life balance but have also increasingly cut into time caring for patients. A Health Affairs study found that the average physician does not have adequate administrative time allotted during working hours, spending more time on administrative “desktop medicine” than patient care.

So why has this happened?

Staffing changes

Reduced staff support makes up one piece of the puzzle. Recent reports indicate that staff are fleeing health care, resulting in a reduction of available administrative support across different specialties. In 2021, 20% of health care workers left their jobs — more than doubling the pre-pandemic rate. According to a survey conducted by the American Medical Association, one in five doctors and two in five nurses intend to leave their current practice within two years. This mass exodus can be attributed to a variety of factors, including the effects of COVID, burnout, and more attractive employment opportunities. (Read more about this staffing trend in DermWorld's feature "The great resignation.")

Physicians report shortages across all roles, and according to the latest findings from The Physicians Foundation, 73% had a significant or moderate shortage of registered nurses. Dr. Houk has also observed this trend in her own practice. “Post-COVID, we are still struggling with staffing issues,” she said. “Less so on the non-clinical side, but we’re still short-staffed on medical assistants and nurses.”

Administrative shifts in medicine

In addition to less staff to go around, data also indicate that the level of administrative burden faced by physicians today is greater than in the past. “The requirements for medical documentation have only gotten more onerous over time. My practice, like many dermatology practices, employs scribes. However, when we’re short-staffed, that may sometimes mean that the practice can’t add on an additional patient at the end of the day if we don’t have the staff to help scribe for that visit.”

Alongside evolving medical documentation and EHR requirements, prior authorizations remain a constant — and growing — pain point for physicians and their practices. A recent MGMA poll found that 70% of medical groups indicated that the use of prior authorizations increased in the last year.

New forms of patient communication have also added more work onto dermatologists’ plates.

In the past, doctor-patient communication was limited to landline phones and physical mail. Now, patients and physicians have a myriad of communication tools at their disposal, including text messaging, email, patient portals, social media platforms, and more.

Physicians and their staff must now monitor and field these different channels, often outside normal office hours and without compensation. “The burden of time put on physicians to answer portal messages is increasing. I’m a huge advocate of the patient portal, however even I acknowledge that it’s a lot of free care we’re providing,” said Dr. Houk. “Some organizations have made the decision to bill a patient’s insurance for portal messages that take the physician longer than five minutes to answer.”

What solutions are available?

Amid these challenges, there are options available to dermatologists to help alleviate increased administrative burden placed on them and their practices.

Specialize staff roles

While hiring additional staff may not be an option for every physician, assigning a designated staff member per issue, with each individual working at the top of their license, may help improve practice efficiency.

Dr. Houk’s organization has recently piloted a similar strategy to help tackle prior authorizations. “I think the most powerful thing is that MaineHealth has committed to creating and funding a centralized prior authorization department. While the prior authorization process is onerous and takes many hours on the phone, you do not need to necessarily understand how the medication works until the peer-to-peer portion. You just need to be able to sit on the phone, give demographic information, and read the history of the medications the patient has tried and failed,” she explained. “So, it makes sense to have a centralized department that only does prior authorizations for all the medical specialties, regardless of what the drug is. The prior authorization process for Aetna is the same for neurologic medications, as it is for dermatologic medications. At a certain point, it might get specialty-specific, but to start the process you can be a relatively untrained individual and be successful. My greatest hope is that large organizations will continue to centralize that process, because prior authorizations are a tremendous burden to our department.”

AAD resources

If hiring or reassigning staff isn’t an option, the Academy also offers members a broad selection of resources compatible with different practice settings to help alleviate administrative burden.  “Increased administrative burden greatly contributes to physician and staff burnout. Therefore identifying ways to ease these burdens and finding practical, sustainable solutions is a key priority for the Academy’s practice management department,” said Wasif. “To that end, there are several existing resources that the Academy offers to help dermatologists find the right solution for their unique needs and practices.”

The AADA Practice Management Center is filled with resources aimed at helping reduce administrative burden. Key tools include:

• The Prior Authorization Resource Center: Access authorization guidelines for staff, troubleshooting for patients, software recommendations that may help fast-track the prior authorization process, and more. The Academy has also created a customizable, clinically specific tool to allow your practice to easily generate individualized prior authorization appeal letters. Get started.

• Health IT (HIT) solutions: Get tips on how to utilize HIT to reduce burden from medical documentation, including advice on mobile apps.

• EHR guidance: Learn how to optimize your system and streamline practice workflow.

• The Private Payer Resource Center: Access Academy resources on navigating issues with private payers, including an appeal letter generator.

• Up-to-date guidance on MIPS reporting: Explore the Academy’s tools and resources to help you better understand MIPS and the Medicare Physician Fee Schedule, including a step-by-step reporting guide, and analysis of MIPS updates for the reporting year.

“All in all, the Practice Management Center has a wealth of resources that can help establish or improve a dermatology practice, and because not every practice is the same, a wide range of solutions and resources are available for members to explore,” said Wasif. “If members have additional or more specific questions, they can reach out to Academy practice management staff at practicecenter@aad.org. Staff will get back to you within two business days with an answer or direct you to expert consultants who can help!”

Portal optimization

While patient portals can be a source of administrative burden, they can also be engineered to help streamline efficiency.

Dr. Houk has implemented a triage system for managing messages received by the portal, ensuring that requests coming in from patients are handled at the top of each staff member’s license. “If a patient wants to cancel or reschedule an appointment, I never need to see that. The clinical staff member assigned to manage the portal at that time can just send it right on to the admin team to reschedule that appointment,” she said. “Another initiative we just started in our practice is when a patient messages with a photo and essentially some paraphrase of ‘What do you think? Should I worry?’, that message goes directly to the admin team. If the admin team can find a visit within seven days of that message coming in, then they offer it. The nursing staff and physicians love it because there’s less back-and-forth with the patient. If they don’t have an appointment within seven days, or the patient pushes back, then we still have the same workflow where the nurse asks questions about the issue or lesion, gets more data, and then forwards it to the physician. It’s a new way we’re using the portal to offload message burden, as opposed to just forwarding everything to the physician.”

Patient self-scheduling

Another emerging tool available to physicians and their administrative teams is patient self-scheduling. “If you’re looking for a restaurant, you go to OpenTable or Resy, find an available date and time, and make your reservation. This is what I believe patients want to do for medical care, particularly younger patients like Gen Z or millennials,” said Dr. Houk. “One program that can achieve this is called Fast Pass, which is something we piloted a year ago in the dermatology department at MaineHealth.”

According to Dr. Houk, the pilot sought to automate the appointment scheduling process and reduce long wait times for appointments. “Currently, a new hair loss consultation with me is somewhere in 2025. However, there are a lot of cancelations in that hair loss clinic, particularly for these new consultations. I don’t particularly care which new hair loss consultation patient is in that spot,” she explained. “If I get a cancelation, patients who use the portal can be added to a waitlist. That generates an automated list, and the program pushes a text out to the first six phone numbers on that waitlist. As soon as someone responds, then the other five people receive a message that the appointment has been taken.”

Artificial intelligence scribing services

Over the past year, emerging artificial intelligence (AI)-powered tools have dominated headlines and prompted broad conversations about their responsible use across different industries. Medicine has recently seen the emergence of AI-powered scribing services, in which AI “listens in” on patient appointments to automatically write up a near-complete note within minutes.

According to Ivy Lee, MD, FAAD, chair of the Academy Augmented Intelligence Committee, there are some potential advantages to the emergence of this technology. “For the clinician, it offers time saved from burdensome documentation, which hopefully translates to improved work-life balance and decreased burnout. For the patient, it may offer increased physician presence, especially since many of these AI solutions are ambient. For the health care system, they may eventually result in decreased costs, more accurate and timely documentation, and more structured data with which to conduct research and fine-tune future AI algorithms. However, research on AI-powered documentation and these potential benefits is nascent and growing.”

While these potential benefits are tempting, there are risks as well, according to Dr. Lee. “The greatest risks include accuracy, privacy, and fairness. There is minimal transparency, and no clear standards or benchmarks for these core principles,” she said. “At this time, it is very hard to figure out how these models were developed, fine-tuned or validated.”

Last year, Dr. Houk’s practice piloted an AI-based scribing service — with mixed results. “I was part of a pilot of around 20 to 30 physicians in ambulatory practices. The program we piloted was loaded onto a physician’s personal phone and would listen in to the visit after receiving the patient’s consent. I would then get an almost word-for-word transcription back usually within 24 hours of the visit, which I could then make edits to. For practices that didn’t have in-person scribes, it was life-changing. We had in-person scribes, so it was not a great substitute for us, but certainly I could see how in a staffing shortage, this could be another option to get help with your documentation.”

“I think physicians are more comfortable using AI to alleviate administrative burden than for clinical decision-making. With the accessibility of large language models and generative AI, clinicians are discovering new use cases.”

In Dr. Houk’s experience, one limitation of AI-scribing was the quality and utility of the note generated by the program. “You would get this very flowery, long note with incredible detail — almost too much detail — but what I really needed was someone to take photos or place orders, and that’s not something the program could do. So, it didn’t eliminate the use of the computer. I’m pretty competent with our EMR, and what I and my colleagues found was that the more efficient you already were with the electronic medical record, the less helpful the program was for you. Dermatology ended up not finishing the pilot, simply because it just wasn’t functional for us and our model. It seemed to work better in non-procedural practices, like primary care, and for individuals who were not tremendously skilled at using the EMR who dictated their notes.”

Questions about accuracy have also emerged alongside the public launch of AI-based scribing services. A recent study from JAMA Internal Medicine compared ChatGPT (an AI-powered learning language model, or LLM) with senior internal medicine residents for composing the history of present illness (HPI) component of a medical note. The study found that without significant prompt engineering, ChatGPT was guilty of hallucinating, or generating false information.

Does AI have the potential to replace human scribes? “That is a difficult question to answer,” said Dr. Lee. “Human scribes vary in accuracy, privacy, and fairness as well. The accuracy of AI-powered scribes will vary depending on the algorithm and its evolution over time. Each health care system and physician must consider the cost-benefit analysis of human versus AI scribes, namely how much of the documentation process they want to delegate, and how much they want to oversee and edit. At this time, I think the current market solutions for AI-powered scribing services still require clinician oversight but can significantly augment our capacity by efficiently drafting documentation, summarizing, and generating personalized patient education, care coordination, and prior authorization letters.”

According to Wasif, the Academy recognizes the expansion of AI-technology and encourages dermatologists to adhere to general principles of human-centered design when integrating such technologies into their clinical practice. “As noted in the Academy’s position statement on augmented artificial intelligence (AuI), ‘patients should feel well-cared for even when interacting with software. Clinicians should spend time conducting work appropriate for their skills and training, while being able to delegate algorithmic tasks to machines, with the goal of enhancing patient care,’” she said. “Further, the Academy recognizes the enormous potential of AuI solutions while also emphasizing the importance of considering the ethical and equitable application of such new tools.” View the Academy’s position on AuI.

Beyond medical documentation, AI and AuI may assist dermatologists in other ways as well. “I think physicians are more comfortable using AI to alleviate administrative burden than for clinical decision-making. With the accessibility of large language models and generative AI, clinicians are discovering new use cases,” said Dr. Lee. “Examples include content creation for marketing, staff training, and more accessible patient education, as well as use of chatbots for scheduling, triaging patient messages, and drafting inbox responses. The creativity of our clinician community is unbelievably inspiring.”

Additional DermWorld Resources