Love them or hate them, Electronic Medical Records (EMR) are here to stay. And that’s not necessarily a bad thing. They don’t have to be painful, but in some cases they have been. I installed my first EMR in 2002 and have installed several since then. As I like to say, even if you “feel” that your EMR deployment was 100% successful, it really means that it failed about 70-80%. Rather than being built by physicians, many EMR and practice management (PM) systems (the part of IT that basically handles billing/coding, scheduling, etc.) in the early 2000’s and before were more likely to be built by IT guys who created the product(s) for what they are for thought the doctors and practice administration needed vs. what they wanted (and actually needed). And there seemed to be a lot of foreign material. My aeronautical engineer buddy uses the technical term “over engineering”.
In any case, good EMR delivery is quite a project that requires teamwork, but EMRs can be effectively implemented to assist physicians in delivering care. Appropriately structured and e.g Physician requirements and workflow, an EMR can help with care delivery, patient flow, care quality management, schedule optimization, and care follow-up; compared to a doctor’s office, the list is endless. However, over time and/or through sheer intransigence, many EMRs have grown into vast collections of clinical “noise” versus useful chunks of manageable data. EMR functionality (generally affected by installation) can force clinicians to seek the path of least resistance, employing workarounds to achieve what used to take them seconds in the days of paper charts.
The reason? Well I’m sure there are many. But clinicians, or their medical assistants, have been trained to “draw up” old notes and data, some useful for history, other information just accumulates and has no clinical or additional value.
While I don’t prosthetize or dwell much on EMRs, I received an email from Eric Bricker, MD, CEO of AhealthcareZ (ahealthcarez.com), who submitted an article to his email list suggesting that the “… .University of Pennsylvania recently published a study in the Journal of the American Medical Association found that 50% of EMR texts are copied and pasted.” (Dr. Bricker has a nice video on this topic on YouTube.) As someone, who has been on the operational side of the company for more than 30 years, I’m not at all surprised. When I think of my personal IM Doc, whom I only see annually for my physical exam, I can only imagine what is stratified in my medical record and what is brought forward year after year. Were I a long-term patient of his (longer than my 16 years), with comorbidities and due to the capture of old paper charts scanned/abstracted into the EMR, the amount of useful information could be lost in the sheer mass of scanned paper.
Aside from the care management risk of a “noisy” spreadsheet that a clinician can only scan through, there is a significant medical/medical risk related to a short-winded pre-visit workup. There are instances where inaccurate information that should otherwise have been deleted is passed from visit to visit; There have actually been cases of malpractice where this has been cleared up. And inaccurate coding based on data that happened to be used to document an E&M visit can lead clinicians to code “situations” (think fraud and abuse). A documented, coded and signed chart is a legal document and (as we said when I worked Medicare fraud 800 years ago) “…if it wasn’t documented, it wasn’t done…”). Given the early dates, you might also ask, “…if it was documented, was it done?”
Example: You have a clinician or a list of clinicians who are on a productivity unit (relative labor value unit). [wRVU]) Comp model. What are the dangers of “overusing” the coding function of the EMR and “pre-allocated” charts? I had a client a while back who suggested that all of his specialists (in a particular specialty) working on a wRVU comp model reached north of 95th% for Comp compared to their peers. In addition, all of them had consistently passed their coding exams. In the eyes of the healthcare system, these clinicians were productive, highly paid, and passed chart audits—bulletproof. However, the customer was concerned that something was wrong – too good to be true. This got me thinking: I took a random sample of their schedules and examined lab and office days. What I guessed is the sample plan seemed (excuse the alliteration) to indicate that clinicians were essentially billing more “time” for patient-centered care than they had available on the clinic day. For example, a visit that lasted 10 minutes was billed at the CPT level for 45-minute visits. This meant providers could use the EMR to ‘document’ the work and meet all documentation requirements to bill for higher levels of care without actually spending the required visiting time with patients.
As you can see, and I’m sure this is neither the exception nor the rule, such things can happen, be it intentional or accidental. The medical record must be curated and carefully managed to ensure that only relevant clinical data is prioritized for each visit. I sometimes wonder if in this age of speed and production we have somehow left behind the accuracy of our documentation.
I think it’s worth noting that I’m not suggesting that clinicians willfully or maliciously inflate codes or falsify documentation. But EMRs can enable doctors to get the most out of a CPT code.
EMRs can be very useful. Healthcare organizations have generally been reluctant to manage the myriad of data points that have accumulated over time. The data that IT systems and EMRs contain can be used in a variety of ways to treat disease, manage populations, or address chronic disease states (e.g., ChF patients, treatment of patients with diabetes, etc.). They must be used as they were (theoretically) designed.