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Electronic medical records and the hijacking of medical documentation

Here’s an editorial of mine, published in our Local Wilkes Barre Times Leader, discussing the pros and cons of the upcoming Federal regulation that requires your physician to record the details of your encounters electronically.

 

 

 

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ONE OF the big changes recently in the practice of medicine is Medicare’s push for physician’s practices and hospitals to convert their documents from paper charts to an electronic medical record (EMR).

Starting in 2011, medical providers are given extra reimbursement by Medicare for adopting and using an EMR.

The mantra from advocates is that EMRs allow easy transfer of a patient’s medical information from caregiver to caregiver, avoid duplication of testing, decrease costs and reduce medical errors. Much of this is probably true. As a physician, however, I worry that EMRs as implemented can actually downgrade the quality of information passed between health care teams and at least, in some ways, increase the cost of care.

Now, I’m a computer-oriented guy. It irks me to see data collection in my office occur through the filing of printed, white cellulose sheets in green cardboard folders – a format with no digital access. I definitely want an EMR.

First problem is that they are rather expensive. The company that supplies my current billing software has offered to install one: for $35,000. For my solo private practice, that’s a lot of money.

Practices spend it, however, because of a benefit to them little talked about in public. Insurance companies, and particularly Medicare, have set up rather convoluted rules regulating physician reimbursement. To determine payment, insurance companies factor in the length of the encounter, the number of “bullet points” in the history, the completeness of the physical exam and the complexity of the “decision making.” The rules are complex. Most of us have a sense of them; but when seeing a patient, it is cumbersome to review the precise rules related to your encounter. Many doctors will guess at the correct billing code involved and, if anything, “under code” the insurance, for fear of fines if the practice is ever audited.

EMR companies buffer the “sticker shock” of a system with an important advantage. First, EMRs have the ability to increase one’s billing codes by documenting the actual complexity of an encounter.

In the long run, Medicare and other insurances judge your encounter by what’s recorded in the patient’s record. During his or her visit did you review your patient’s medications or their past medical history and/or social history? Most caregivers would, but don’t take the time to document it. Now, with a couple of mouse clicks, the data is drawn into the encounter note. Suddenly your documentation is brimming with “bullet points.” The software also can draw in recent lab data, radiologic results or any data available in the system digitally. A 10-minute encounter can look, in the record, as if you spent an hour with the patient. I’m not saying that providers are defrauding insurers, but I suspect the ease of documentation facilitated by an EMR certainly lets them “capture” all of the value for each patient visit.

Now here’s the really compelling part of the EMR sales pitch: Once the note is digitally recorded, the software can analyze your patient encounter and suggest the actual billing code. No more “under coding.” EMR vendors speak of $10,000 to $20,000 of income added to a practice’s bottom line per practitioner. In fairness, by the insurance company’s own rules, it is money owed to providers; but in this setting, the technology is definitely not decreasing costs.

In the case of large health care systems, all of the provider advantages are magnified. Plus, everyone in the system working with a patient has access to a single electronic chart with all the clinical data. I have access to a system such as this and it can be wonderful. The governments’ plan is that in the future all EMRs will be able to talk to each other in this fashion.

There are other problems, however. As EMRs proliferate, and increased Medicare scrutiny looms, medical documentation is evolving from its original goal of recording what actually was going on with a patient, and what the provider was actually thinking, to sterile boilerplate documents designed to justify the highest billing codes.

In years past, a well-written history and physical, or progress note, would unfold like a story, giving a vivid description of the patient’s symptoms and physical exam at the point of the encounter, as well as the synthesis of the data and the plan of care.

In an EMR an “H and P” is often reduced to random collections of data combined digitally with sterile prose that describes weakly, if at all, the clinical situation.

This problem occurs because most physicians don’t type fast enough to be efficient using an EMR. Because of this, they are prompted to use what EMR companies refer as “smart phrases,” pre-composed text designed for relevance in a broad range of circumstances. Dictation into the record is sometimes an option, but transcription is expensive.

So most electronic medical records tend to be full of data, but short on nuance. I currently dictate most of the notes in my office and hope that they convey my exact thoughts to my colleagues. I do worry that an EMR might degrade this.

Much of my inpatient work is at sub-acute facilities and involves accepting transfers from acute care hospitals. Because of this, I often have to review complex hospital records. Given the current technology, old-fashioned written notes, which tend to be brief but focused on the important details of care, are far easier to digest than their all-inclusive, and often repetitive, digital counterparts.

So how do we improve EMRs? First, I think we need to find a way to separate the documentation for billing’s sake, from that needed for patient care. These are supposed to be medical records for clinical use, not part of a contest between medical billers and insurance companies.

We need to provide a way for practitioners to document their exact thoughts in the electronic record in a cost-efficient way. This might happen as younger caregivers, who tend to type, come into the work force. I hope that improvement in speech-to-text software will be a solution for us more “established” physicians.

As I am hopefully in the middle of my career, I am extremely excited about the potential for this technology. I look forward to the efficiency and improvements in quality it might bring.

I just don’t want it to highjack my documentation for its own purposes.

 

Dr. Henry F. Smith Jr., a Fairview Township resident, practices pulmonary medicine in the Wilkes-Barre area.



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