Monday, August 30, 2010

Documentation Requirements are the Enemy of EMR

After 5 successful years with electronic medical records (EMR) I am convinced that the promise of EMR to improve physician practices and to improve the health care system is real.  If that is true, why is adoption of EMR currently limited to only 5 - 10% of medical practices?  Why is there so much resistance?  As folks who work in heath care IT so often ask, why don’t doctors “get it?”  I don’t mind the question but I do object to some of the sinister explanations that are offered.  Physician resistance to EMR is legitimate.  This post will explore one of the reasons for doctor resistance to EMR.

A few years ago one of our best referring physicians came to see me as a patient.  After we took care of his medical issues, I asked him how he liked our new EMR and the notes we were sending him through it.  His answer floored me: "I hate it."  That is NOT what you want to hear from one of your best referring physicians.  After a moment of drop-dead silence he added, "nothing personal.  I hate all the EMRs out there, including the one our practice just bought."

He went on:  "Notes that come from an EMR have so much extra stuffing in them that it takes me forever to figure out what you guys really had to say about the patient I referred to you.  I have to wade through lines and lines of empty verbage to finally find a meaningful sentence or two that tells me what I need to know.  Our own EMR notes are no better.  But there's nothing we can do about it, we just have to accept it."

Except for that last part, he is absolutely right.  Why did things get so bad?  

Doctors used to document their work with concise handwritten notes.  (See my last blog).   Then came CPT codes, which brought elaborate documentation requirements that medical records must fulfill in order to receive payment from the insurance provider.  These requirements measure the documentation, not the care itself.   Fear of documentation errors often force providers to code and bill at a lower level than their work truly deserves.  Physician revenues are thus limited not by the amount of real work performed, but by the sheer number of words one must write to properly document that work.  As long as chart notes had to be handwritten or manually dictated and transcribed, CPT effectively limited physician billing.  Providers became as much servants to documentation as they were caregivers.

This situation inspired the first marketing efforts by EMR vendors to physicians.  Recognizing the need, vendors promised improved, automated documentation and monitoring of charts for CPT compliance.  Doctors could finally bill safely at the appropriate CPT level.  With just a few mouse clicks the chart note can fulfill all the requirements to be CPT-compliant.  Now the physician can concentrate on the patient again.  In my experience this has worked well. 

But sometimes it's the side effects that kill.

EMR shows us what fully CPT-compliant documentation looks like. And it's awful. The folly of carrying CPT documentation requirements into the information age has been exposed. The relevant data are buried in a sea of white noise - patient demographics, irrelevant historical data, normal physical findings, and diagnosis / billing codes.  Each mouse click generates a bland, repetitive phrase in order to hit a CPT-mandated "bullet point."  The result is a multipage, single-spaced, small font monster of a chart note with very little substance relative to its size.   This obsession with documentation is distracting both EMR vendors and users from pursuing the real benefits of EMR - automation of workflow, rapid data exchange, reduced costs and improved efficiency.

Want a real incentive for docs to get EMR?  Forget HITECH.  Few doctors I know believe those incentive payments will ever happen.  All but the largest practices and major institutions will be defeated by "meaningful use" criteria.  Instead offer EMR users freedom from CPT documentation requirements.  Replace CPT with a system that is appropriate for the information age.  Leverage the power of EMR and create a system that rewards quality of care rather than volume of documentation. 

Easier said than done.  But recognizing the problem is the first step.

Thanks for reading.


Saturday, August 21, 2010

From Notecards to RAC’s: The Evolution (and Nightmare) of Medical Records

Medical record keeping used to be simple. 

I was born in the early 1960's and saw my pediatrician for regular checkups and common illnesses until going to college in 1980. The first 18 years of my medical care were completely summarized on five 5 X 7 notecards contained in a manila packet. Each of my visits was documented by a 1 to 5 line handwritten note.  There were no wasted words.  My pediatrician also set the standard for illegible doctor's handwriting!

How could my pediatrician get away with such a thing? In those days medical records served only one purpose: they were the physician's personal notes taken to assist him or her in future care.  The only outside request for my medical records was made to show I had my immunizations.

Things began to change in 1966 when the American Medical Association created Current Procedural Terminology codes, or CPT codes. The original set of codes addressed medical procedures only and did not include office visits.  A physician's bill to an insurance company for an office visit instead contained a narrative of the patient's symptoms and the care that was given.

Over the next three decades events conspired to make medical records far more complex. The emergence of comprehensive health insurance, including Medicare and Medicaid, separated the consumer of health services (the patient) from the payor of health services (the insurer). Because the payor for health services no longer directly witnessed the patient encounter, the medical record became a necessary instrument of proof that service was delivered. A single phrase record such as “severe tonsillitis” no longer sufficed.  CPT was revised to include codes that covered office visits ranging from simple level 1 visits to complex level 5 visits. Each level specified a set of documentation criteria that medical notes had to meet in order for the doctor to bill at that level.

Then medical liability was created.  The medical malpractice lawsuit, once considered inconceivable, became commonplace. Physicians were compelled to add even greater detail to their medical records in order to defend themselves against potential accusations of inadequate care. In training I was taught, “if you didn't document it, you didn't do it.”  Thus defensive medicine and defensive record keeping was born.

Next came managed care.  Under the guise of cost control insurers came up with a variety of tricks in order to delay and decrease payments to physicians. One of the most popular games was to use the minutia of CPT coding requirements as a means to reduce and/or deny payments. A physician can spend 45 minutes working up a complex, very ill patient, compose an extensive clinic note, and have payment denied because the “review of systems” in the note was technically (but not clinically) inadequate.   In more recent times CPT coding and the supporting medical record documentation have become so complicated that an entire industry has formed for the sole purpose of understanding CPT coding and training / certifying individuals in this new body of knowledge.

Another popular managed-care technique, still in use today, is pre-certification. In most insurance plans a surgeon cannot expect to be paid for an operation unless he gets prior approval from the insurer prior to performing the procedure.  Pre-certification is often not given unless the medical record documents the need for the procedure. This puts yet another burden on the medical record.

Finally, we have the ever-increasing threat of practice audits coming mostly from the federal Office of the Inspector General.  An audit includes an exhaustive review of the physician's billings to Medicare and a comparison of those billings to the corresponding medical records to be sure the records support the level of billing. Even the most conscientious physician fears the OIG audit, knowing that even the best documentation occasionally fails to meet the minutia of CPT coding requirements.   In some states these audits are now being performed by privately contracted firms (called recovery audit contractors or RAC's) that are incentivized to find problems and levy fines.  RAC auditors are not held accountable for their actions.

The future promises further obligations on medical record keeping.  Pay for performance, benchmarking, outcomes research and other similar plans will raise the bar even higher.
What began in the mid-20th century as simple professional note keeping has grown into a regulatory and liability behemoth, creating a burdensome obligation for the 21st century physician.  The medical record serves not only as the provider's reference but also as documentation of service, support for billing, support of proposed future care, defense against lawsuits and as a data capture instrument for outcomes research and future pay for performance initiatives.  The medical record must often face hostile audiences such has malpractice attorneys seeking liability or managed care providers looking for reasons to deny payment to the physician.  With the possible exception of RAC audits I don't regard any of the above concepts as inappropriate.  But they do make record keeping much more difficult. 

Into this complex and rapidly changing environment comes the electronic medical record (EMR), trying to hit a poorly defined, rapidly moving target.  And EMRs have additional hurdles made just for them, including CCHIT certification and the ever changing / growing "meaningful use" criteria.

In the next post I will review how the regulatory burdens on medical record keeping distract the EMR from its best, most noble goals: improving efficiency, lowering costs and improving quality of care.

Thanks for your time and interest.  Comments and corrections are welcome.


Saturday, August 14, 2010

Why did I create this blog?

Electronic medical records is getting lots of attention these days, especially with the Federal Government's incentive program regarding "meaningful use" implementation of EMR.  In our practice, ENT of Georgia we are in our 6th year of EMR, so we are far ahead of most.

Over the past 5+ years we have learned a great deal about bringing a medical practice into the information age - not just EMR but a host of other functions as well.  I hope to share what we have learned.