The electronic medical record was created to make it easier to practice medicine. But the unintended consequence of the EMR was that it made it easier for regulatory agencies to tack on additional documentation requirements. It is the documentation excess that doctors hate. But like Pavlov’s dogs, we’ve come to associate that documentation excess with the electronic medical record. At its core, the EMR is just a place to store information about patients, just like the paper charts kept in manila folders that we used 20 years ago.
A study of the use of the EMR in emergency departments found that the average patient encounter required 194 mouse clicks. In a typical office practice, that number is probably about half that – let’s just say 100 mouse clicks. But as we move further toward value-based purchasing and risk-adjusted billing models of reimbursement, the number of mouse clicks per encounter will continue to increase. Lets take a look at where all of those mouse clicks go. We’ll start with a hypothetical patient who comes to the office for a return visit to check his blood pressure. What you really need to document is: “BP = 154/94 on hydrochlothiazide. Will add lisinopril 5 mg/day. Patient also has edema; will check creatinine and cardiac echo. Return to office in 2 weeks.” If you look back at hand written charts from 30 years ago, that is exactly what the progress note would say and it would have conveyed everything that the doctor needed to know about for that particular encounter and the doctor would have billed for a level 4 return visit (on the 1-5 scale of return visits). But today, to bill that level 4 return visit, the doctor has to add more documentation and all of that documentation requires mouse clicks. Here is the additional work that is now required in order to complete the encounter:
If you add all of that up, it is a minimum of 34 mouse clicks (plus a lot of additional keyboard typing of various words) to complete the encounter and none of those 34 mouse clicks really adds to the care of the patient. Clever physicians have developed work-arounds in order to avoid having to do excessive documentation.
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For example, they will create templates for their electronic medical record encounters that have all of the documentation elements for “history”, “past medical history”, “review of systems”, and “physical exam” pre-populated in their encounter note based on a typical normal patient, after all, the only person who would ever really look at all of that information is a Medicare coding auditor.
Other physicians will use strategies in the electronic medical record to automatically import information like the medication list, problem list, and allergies that had been previously entered into the electronic medical record during previous office visits – this results in long tables of data in the progress note with the result that the note is virtually unreadable to the clinician but has all of the necessary elements for the Medicare coding auditor to count.
Medicare requires all lab and imaging tests to be associated with a diagnosis and each test has a limited number of diagnoses that Medicare will accept in order to approve that test for payment. So, for example, Medicare will pay for a chemistry panel test for a diagnosis of “high risk medication use” but not for a diagnosis of “asthma”. On the surface, this sounds reasonable. But in practice, this can drive physicians crazy when they have to enter three or four diagnoses for an ordered test before they find one that Medicare (and therefore the electronic medical record) will accept for that particular test. Clever physicians have discovered diagnoses that can be used as “universal keys” to unlock the orders for commonly ordered tests – for example, the diagnosis “unspecified dyspnea” will work for just about any common lab test as well as an EKG, cardiac echo, chest x-ray, or pulmonary function test. Therefore, physicians often put “unspecified dyspnea” as a diagnosis, regardless of why the patient is being seen, just so Medicare will approve the test that they ordered.
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The frustrating thing about documentation requirements is that regulatory agencies are always adding new requirements and they rarely if ever take away old documentation requirements. In other words, the number of mouse clicks per patient encounter grows each year, instead of shrinking each year.
A typical physician will schedule return patient visits in the office every 15 minutes. That means that they have 15 minutes to take an interval history from the patient, do a physical examination, review test results, counsel the patient, document the encounter, prescribe any medication refills, order any new tests, send a letter to the primary care physician, and complete the bill for that encounter. As the documentation mouse clicks add up, the physician has 2 choices: either extend the time for scheduled return visits to 20 minutes or reduce the amount of time spent talking with the patient. The net result of extending the encounter time to 20 minutes would be to reduce by 25% the total number of patients that can be seen in a day – this is not a viable option if the physician wants to stay in business. Therefore, each extra mouse click comes at the cost of a few seconds of time that would have otherwise been spent talking with the patient.
Mean is that they hate all of the excess documentation that they have to do with the electronic medical record. It’s like of like hating pencils because you have to use them to fill out your IRS tax forms each year.
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I am a Professor Emeritus of Internal Medicine at the Ohio State University and former Medical Director of Ohio State University East HospitalDespite millions of dollars and thousands of hours of doctors’ time, patients and their providers often find they have no way to access a patient’s full medical history. Here’s why it’s taking so long.
Seema Verma, administrator for the Centers for Medicare and Medicaid Services (CMS), was returning to Washington, D.C., after a weekend with her family when she received a panicked call from her daughter. Her family had been waiting for a connecting flight home to Indianapolis, Indiana, when Verma’s husband collapsed and stopped breathing.
“If it weren’t for the bystanders and the first responders at the airport, my kids would’ve watched their father die, ” Verma told an audience at the Healthcare Information and Management Systems Society (HIMSS) conference in March 2018. Unfortunately, because his health care records weren’t immediately available, those first responders and the medical team at the Hospital of the University of Pennsylvania knew almost nothing about his medical history. Verma tried desperately to round up the information they needed, making calls back to her husband’s doctors in Indianapolis. Over the next week, doctors eventually discovered the cause of his cardiac arrest and successfully treated him. But even when her husband was finally released, getting the records from his weeklong treatment transferred to his doctors back home was a struggle.
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Verma used her dramatic personal story to introduce a new CMS initiative, called MyHealthEData. Its goal: to make Medicare and Medicaid patients’ medical records far more accessible, both to physicians and patients, and avoid the uncertainty, delay, unnecessary tests and procedures, and needless dangers her husband faced. By giving patients more control over their own medical data, she told conference attendees, MyHealthEData will help patients make better health decisions and even spur innovation and advance research to cure diseases, which would drive down costs and improve health outcomes.
Virtually everyone agrees that making electronic health records (EHRs) fully portable would mean better care at a lower cost. But while the goal of MyHealthEData is laudable, critics were quick to point out that the announcement fell far short on details about how it would be accomplished.
There’s good reason for skepticism. The health care world has been talking about portability of EHRs for almost two decades. “And we’re a long way from that goal, ” says Julia Adler-Milstein, PhD, associate professor and director of the Center for Clinical Informatics and Improvement Research (CLIIR) at the University of California, San Francisco, and an internationally-recognized expert on health care IT. “All you have to do is look at how many medical offices still use faxes to know how far we still have to go.”
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The cornerstone of making patient’s health records portable is interoperability — the ability of one EHR system to talk to another and allow patients and providers to exchange health care information with a minimum amount of time and effort. The goal of interoperability was first enshrined in policy in the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act, which specified that one of the required capabilities of a certified EHR system was “health information exchange.” The 21st Century Cures Act, passed in 2016, required that certified EHR systems be interoperable in order to be considered Certified Electronic Health Record Technology (CEHRT).
“That hasn’t happened, ” says John Meigs, Jr., MD, board chair of the American Academy
I am a Professor Emeritus of Internal Medicine at the Ohio State University and former Medical Director of Ohio State University East HospitalDespite millions of dollars and thousands of hours of doctors’ time, patients and their providers often find they have no way to access a patient’s full medical history. Here’s why it’s taking so long.
Seema Verma, administrator for the Centers for Medicare and Medicaid Services (CMS), was returning to Washington, D.C., after a weekend with her family when she received a panicked call from her daughter. Her family had been waiting for a connecting flight home to Indianapolis, Indiana, when Verma’s husband collapsed and stopped breathing.
“If it weren’t for the bystanders and the first responders at the airport, my kids would’ve watched their father die, ” Verma told an audience at the Healthcare Information and Management Systems Society (HIMSS) conference in March 2018. Unfortunately, because his health care records weren’t immediately available, those first responders and the medical team at the Hospital of the University of Pennsylvania knew almost nothing about his medical history. Verma tried desperately to round up the information they needed, making calls back to her husband’s doctors in Indianapolis. Over the next week, doctors eventually discovered the cause of his cardiac arrest and successfully treated him. But even when her husband was finally released, getting the records from his weeklong treatment transferred to his doctors back home was a struggle.
All You Need To Know Ehr Implementation In Billing
Verma used her dramatic personal story to introduce a new CMS initiative, called MyHealthEData. Its goal: to make Medicare and Medicaid patients’ medical records far more accessible, both to physicians and patients, and avoid the uncertainty, delay, unnecessary tests and procedures, and needless dangers her husband faced. By giving patients more control over their own medical data, she told conference attendees, MyHealthEData will help patients make better health decisions and even spur innovation and advance research to cure diseases, which would drive down costs and improve health outcomes.
Virtually everyone agrees that making electronic health records (EHRs) fully portable would mean better care at a lower cost. But while the goal of MyHealthEData is laudable, critics were quick to point out that the announcement fell far short on details about how it would be accomplished.
There’s good reason for skepticism. The health care world has been talking about portability of EHRs for almost two decades. “And we’re a long way from that goal, ” says Julia Adler-Milstein, PhD, associate professor and director of the Center for Clinical Informatics and Improvement Research (CLIIR) at the University of California, San Francisco, and an internationally-recognized expert on health care IT. “All you have to do is look at how many medical offices still use faxes to know how far we still have to go.”
Essential Digital Healthcare Technologies And Its Usage
The cornerstone of making patient’s health records portable is interoperability — the ability of one EHR system to talk to another and allow patients and providers to exchange health care information with a minimum amount of time and effort. The goal of interoperability was first enshrined in policy in the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act, which specified that one of the required capabilities of a certified EHR system was “health information exchange.” The 21st Century Cures Act, passed in 2016, required that certified EHR systems be interoperable in order to be considered Certified Electronic Health Record Technology (CEHRT).
“That hasn’t happened, ” says John Meigs, Jr., MD, board chair of the American Academy
