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Spring 2013

Health Information Management Challenges in the World of EHR

Joette Derricks, CPC, CHC, CMPE, CSSGB
Vice President of Regulatory Affairs & Research, ABC
From the Spring 2013 issue of The Communiqué

There is no doubt that the emergence of the Electronic Health Record (EHR) program is changing the way providers capture documentation on the front end. According to the 2012 NCHS Data Brief, 55 percent of physician groups have already adopted an EHR. Among the 45 percent that have yet to implement an EHR system, nearly half plan to purchase or use a system already purchased this year.1 Hospitals are also purchasing and installing EHRs at a rapid rate.

EHR templates are rapidly gaining footholds despite some growing pains. CMS has issued advice on the use of checkboxes and drop-down menus accommodating discrete data capture. Despite access to such “documentation tools” via point-and-click templates, most physicians are complaining that it takes longer to document an encounter in an EHR than to previously dictate it. The RAND Corporation released a paper describing the phenomenon that occurs when an industry’s technological capabilities improve at such a dramatic pace that end-user productivity actually drops. Known as the IT productivity paradox, it demonstrates a link between poor design and usability that undermines productivity gains.2

To increase productivity with EHRs many vendors are now offering speech options within their systems. Other physicians unhappy with the technology have given up and moved to medical scribes or documentation assistants to deal with “feeding” the EHR.

Regardless of how the information gets into the EHR, once it is there it can present challenges to health information management (HIM) specialists, including coding and auditing personnel. Universally, HIM departments and coding/auditing specialists, along with the provider community, have noted the increase in volume of computer-generated records. A previous encounter in an outpatient setting that may have required a half-page report to capture the pertinent clinical data now is five or more pages of information. With the volume of information now flooding HIM departments, coders and auditors are faced with some serious issues regarding how to make sense of it all. The key question they face from a coding and auditing perspective is, “What is relevant to this particular patient’s encounter?”

Many coding consultants and trainers have long taught physicians it is not the volume of the note but the quality of it that counts. Ever since the 1995 Evaluation and Management Services (E & M) Documentation Guidelines came out, coders, and payers too, knew that physicians could over document by providing unnecessary information to pad the note. Using an EHR in some respects makes it easier; however, such padding often occurred when dictation and transcript services were state-of-the-art. Physicians often relied on “canned” text that their transcriptions would insert based on a few words, e.g. “normal adult male exam” now they merely double-click the option. Perhaps the CMS advisement regarding this type of over documentation is rooted not in the use of templates by the physician per se, but in how the coder, or the billing system if an auto-coder is imbedded with the EHR, uses the information to bill the service.

In working with coders and auditors, it is often best to have them first focus on the presenting problem and the management or treatment option presented in the documentation. This advice is in agreement with CMS and many other payers that have gone on record regarding the importance of the medical decision making guidelines in the selection of the E & M code. Medicare’s definition of medical necessity requires that paid services meet but not exceed the patient’s medical needs and be provided in accordance with accepted standards of medical practice. Accordingly, Medicare carriers state that the patient’s condition (e.g., severity, acuity, number of medical problems) is the key determinant for the frequency and intensity of E & M services for which Medicare pays. Coding E & M services first on the basis of medical necessity followed by verification of documentation of required key work components for the selected code allows coders and clinicians to avoid several common pitfalls of E & M coding. WPS Medicare’s website states, “Providers can ensure accurate Medicare payments with correct documentation of MDM for E/M services. Medical decision making is generally easier for an already diagnosed problem than for an undiagnosed one. In addition, problems which are improving or resolving are less complex than those which are worsening or failing to change. Keep in mind that MDM should reflect the nature of the presenting problem. Treatment for a common ailment, such as an ordinary cold, will not usually warrant a comprehensive level exam.”3

Other challenges regarding EHR usage for HIM professional include:

  • Identifying and correcting inconsistencies within the same note. For example, the physician would indicate the patient’s pain level was at a level 6 in the history of present illness and in the exam documentation that the patient was in no pain.
  • Weeding out errors attributed to default functions. One large New York health system has numerous patients with family members without a heart. An ongoing erroneous default in the EHR design results in this condition when the physician does not add family history during the encounter.
  • Resolving through physician queries and purging outdated or “perpetuating” data such as a medical problem long since resolved as still being unresolved or a medication as being current long after it was stopped. These errors are often due to the cut-and-paste or carry forward function. While challenging to the coder, a greater concern is the risk of harm to the patient by including outdated information in the encounter documentation. This type of error also can attribute to a “got you” malpractice issue when the physician did or did not address or treat the condition.

One final challenge on the HIM department’s plate now that will rapidly grab the attention of all physicians is the upcoming implementation of ICD-10. Known as a super-granulated coding system, ICD-10 will require some massive rewriting of EHR templates to ensure sufficient documentation is present to code the service. While point and click technology is presenting challenges today to EHR productivity, some consultants are anticipating the detailed documentation required to select an ICD-10 code may decrease productivity by up to 50 percent for both physicians and HIM professionals come October 1, 2014.

Watch for future articles in the Communiqué addressing how physicians may best prepare for the upcoming ICD-10 challenges.

1 NCHS Data Brief, No.98, National Center for Health Statistics, 2012
2 Unraveling the IT Productivity Paradox—Lessons for Health Care,by Spencer S. Jones, Paul Heaton, Robert Rudin, Eric C. Schneider, New England Journal of Medicine, v. 366, no. 24, June 2012, Perspective, p. 2243-2245

Joette Derricks, CPC, CHC, CMPE, CSSGB serves as Vice President of Regulatory Affairs and Research for ABC. She has 30+ years of healthcare financial management and business experience. Knowledgeable in third-party reimbursement, coding and compliance issues, Ms.Derricks works to ensure client operations are both productive and profitable. She is a long-standing member of MGMA, HCCA, AAPC and other associations. She is also a sought-after nationally-acclaimed speaker, having presented at AHIMA, Ingenix, MGMA and HCCA national conferences. You can reach her at