Shock and Awe: EHRs Work as Designed

Shock and Awe: EHRs Work as Designed

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The health care crowd is abuzz with The New York Times revelation that Medicare billing rates seem to have increased by billions of dollars in parallel with increased adoption of EHR technologies for both hospitals and ambulatory services. The culprit for this unexpected increase is the measly E&M code. Evaluation and Management (E&M) is the portion of a medical visit where the doctor listens to your description of the problem, takes a history of previous medical issues, inquires about relatives that suffered from various ailments, asks about social habits and circumstances, lets you describe your symptoms as they affect your various body parts, examines your persona and proceeds with diagnosing and treating the condition that brought you to his/her office or hospital.

The more thorough this evaluation and management activity was, and the more complicated your problem is, and the more diagnostic tests are reviewed, and the more counseling the doctor gives you, the more money Medicare and all other insurers will pay your doctor. Makes perfect sense, doesn’t it?

In 1995 and again in 1997 Medicare has specified exactly how to measure a doctor’s thoroughness by creating 5 levels of visits and defining each level’s complexity in terms of an exact number of questions a doctor asks, and an exact number of organs and body parts that are addressed during a visit. The more sanctioned questions and body parts are addressed, the more money the doctor gets from the payer. During the olden paper days, no physician in his right mind would go to the trouble of actually writing down all these largely irrelevant things, and since Medicare always threatened to audit physician billings, most doctors practiced “defensive billing” and consistently charged less than they should have, because the hand written documentation was rarely indicative of the actual level of service. Enter Electronic Medical Records.

Since before the HITECH act and before the Meaningful Use epidemic, EHR vendors promised doctors an automated way of documenting a visit, so they can spend more time with the patient and not have to constantly write things down. Instead, a click on a couple of boxes would do that for them. Furthermore, physicians won’t have to waste money on expert coders to go through their scribbled notes and figure out a visit level. The software will automatically calculate the appropriate E&M code, based on boxes clicked. Structured data can be very useful for calculations. To make the entire process most efficient, three methods of documentation have been developed to replace hand writing and to efficiently minimize the need for extensive box-clicking.

  • Documentation by Exception – Every EHR has this “feature” allowing the documenter to click on ONE box usually at the top of the page which generates a professional sounding clinical sentence for each organ or body part stating that everything is perfectly normal, or that all your histories are unremarkable in any way. This is a great efficiency to be applied presumably after the interviewer ascertained that all is well with your past and present relatives and body parts. If something is wrong with one or two organs, the clinician can click the Normal button and then edit the exceptional few organs that are affected today, thus obtaining documentation for a complete review or examination of all your systems. Remember that every organ and family member documented is worth a few more dollars according to Medicare’s fee-for-documentation model of reimbursement. No wonder then that this is now a basic feature in every EHR.
  • Pre-filled Templates – These go by different names, but they are a huge time saver for simple and common problems and here is how they work: Let’s say you see a patient with an URI and it is flu season. You document the visit de novo starting from a blank URI template, use all the previously described efficiencies and generate a lovely visit note for this patient. It then dawns on you that you are likely to see hundreds of similar patients in the months to come, and that you always go about these things the same way asking the same questions and getting the same answers. You can save this visit note as a pre-filled template sans patient demographics and histories (really just the HPI, ROS, Exam and for the brave also Assessment and Plan) and when the next URI patient shows up, you can load this pre-filled template and edit exceptions, if any. Since technology is magical, EHRs will also load the patient specific histories and merge them into your brand new note automatically. Two or three clicks will get you enough documentation to allow your EHR to calculate a very nice E&M code and generate enough documentation to keep the payers at bay.
  • Bring Forward – This is really sweet for complex patients with chronic disease that come to see you every few months or so. We all know that not much changes in a few months and most likely everything you will be documenting today is exactly what you documented six months ago. Instead of starting from scratch every time, EHRs have created great efficiency by making it possible for the documenter to bring forward, or load, the previous visit note and allow him/her to edit and make changes based on today’s visit. This beats the old “copy & paste” by a mile, and with a click of a button you have all the organs and relatives and complexity of decision making documented in minute detail. You can now make a few changes here and there as necessary, and the EHR will calculate the appropriate E&M code.

There are other features in most EHRs that are designed to improve reimbursement, but these are the most popular. There are also administrative functions embedded in larger EHRs that allow those who employ physicians to ensure that the docs click on all the necessary things to ensure optimal billing and payment. It is very easy to be critical of clinicians in these scenarios, but let’s remember that if Medicare wouldn’t have defined the value of a doctor visit to be proportional to the amount of text generated during the visit, none of this would have happened.

So the “unintended consequences” of pushing physicians to use EHRs seem to consist of doctors actually using EHRs, as effectively as possible, to document all the little details Medicare wants to see. This can only surprise people who had no clue what EHRs are, how they work, and how they are used in everyday practice, which did not (does not) prevent said people from proclaiming themselves as health care experts, best suited to set the national agenda for EHR design and adoption.

Bonus Tip: Now that everybody has been properly shocked by the E&M coding efficiency introduced by EHRs, I would suggest examining the efficiencies introduced by the variety of “smart” order-sets.

Margalit Gur-Arie was COO at GenesysMD (Purkinje), an HIT company focusing on web based EHR/PMS and billing services for physicians. Prior to GenesysMD, Margalit was Director of Product Management at Essence/Purkinje and HIT Consultant for SSM Healthcare, a large non-profit hospital organization. She shares her thoughts about HIT topics and issues at her blog, On Healthcare Technology.

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44 Comments on "Shock and Awe: EHRs Work as Designed"


Guest
Legacy Flyer
Sep 24, 2012

In essence the Feds have been “hoist with their own petard”

Guest
southern doc
Sep 24, 2012

Ms. Gur-Arie hits another one out of the park. Great post!

Guest
Sep 24, 2012

Indeed. Tweeted and cited.

” Every EHR has this “feature” allowing the documenter to click on ONE box usually at the top of the page which generates a professional sounding clinical sentence for each organ or body part stating that everything is perfectly normal, or that all your histories are unremarkable in any way.”

That has always bothered me. NO ONE falls for that mechanical SOAP “narrative.”

Guest
bird
Sep 24, 2012

Great Post, Perfect timing, Just had a lecture from legal stating that docs are now going to be targeted by CMS if you use templates, carry forwards, copy and paste. I have never forgotten the article quoting Jonathon Bush ceo of an ehr company stating that the EHR is all about control. I think we are seeing that now more then ever.

Guest
rbaer
Sep 24, 2012

In my experience, this is only half true.
-for the ROS, it is sufficient to document that “the remainder of a complete ROS is negative”. I usually ask questions to cover all systems, but I doubt every doc does. In other words, you don’t need EMR to document a lot in a wink
-a lot of complexity is actually based on decision making – for instance, prescription medication counts more than “take an aspirine’ but less than “we need to get you to an ER/OR for surgery right away”.
-cognitive medicine is relatively underpaid, depending on the situation and payor (e.g. medicare vs medicaid), it is somewhat understandable that physicians want to upcode, also considering that a cognitive eval may go along with various unpaid services (answering telephone/Email questions, refills, forms).
-it is in general very hard to deduct easily from a note what the provider did and how much time he/she spent (a doctor usually can, but there is subjectivity to it). One can easily blow up a note, so word count would not help, and the codes – in a somwhat clumsy and complicated way – try to address what a physician actually did. Time based billing is not an option because some patients and docs would engage in endless chatter, maybe pleasant and stress reducing for both patient and doc, but economically not viable.

Guest
Leo
Sep 24, 2012

Yes, shocking, people and their technologies document and do what you pay them to document and do. Technology always has the potential to accelerate dumb practices. Incentives are the culprit. Technology only does what you ask it to, and usually, that involves trying to make more money or save time, or both. When we ask technology to improve health rather than increase billing, it will do that, too.

Guest
steve
Sep 24, 2012

Is part of our problem implementing EHRs a reflection of how far the medical industry lags in general IT adoption. As aprt of a project to get EHRs working for our group, I found out that none of the hospitals in our network or in our area, and none of the surgicenters even collect email addresses from patients. All communication is by phone or snail mail. Does this sound like a problem to anyone else?

Steve

Guest
rbaer
Sep 24, 2012

Email is considered not sae enough for confidential information. I never inquired how the Email variant in our Epic EMR (“my chart”) works around that problem.

Guest
Sep 24, 2012

I would assume that Epic sends a regular email telling the patient to log into their portal, which is secure, to see the information you are “sending” them.

Guest
J.T.
Sep 24, 2012

Is it any shock that during this grand EMR rollout with FFS still present in most of the payment system that services billed would increase (the original function of most legacy EHR systems was for billing, duh)? We will only be able to judge the efficacy of these systems for cost-control after both the public and private sectors stomp out FFS and institute quality based reimbursement systems with radically different incentives.

Guest
Bobbi
Sep 24, 2012

I have audited 1,000s of MD records (defensively) and these templates are often used effectively. But, they are also a dead giveaway when someone is just clicking all of the boxes—for example, a physical statement reads that the “breasts were palpated for lumps” when the patient has had a double mastectomy in their history. Further, the weight of Medicare’s payment law rests on medical necessity. If the patient comes in and their condition or complaint list has not changed materially, there is no grounds to bill for a higher level code, no matter what template you use or how many boxes you check.

Guest
Sep 24, 2012

I don’t think doctors are using these features to commit fraud. I think they are using them to support claims for more realistic levels of payments.
There are always exceptions, of course….

Guest
Bobbi
Sep 24, 2012

I don’t think they are either (except those that generate charges for no patient at all). But, because the E/M code requirements are so dependent on numbers of systems and such, they believe that checking each box entitles them to a higher level visit and that is just not true. But, the AMA and CMS have done a poor job of communicating that.

Guest
Sep 24, 2012

rbaer, obviously not everything is applicable to every situation, but the templated note has made generating, counting and calculating infinitely easier. Add to that boxes that you can check for complexity of decision making, tracking of diagnoses addressed, tracking of labs reviewed, box for >50% counseling, etc. and you have a perfect E&M machine, which not only calculates an appropriate level, but also maintains supporting documentation for posterity.

Personally, I don’t see anything wrong with that. I am thrilled to see that EHRs delivered on their main selling point and as Leo said, now let’s ask for something else and see if they deliver. The problem is that your hospital (or whoever writes the check) will have to ask for these things. Do you thing anybody is asking technology to “improve health” at this time?
Patients may, but patients are not directly paying for technology….

As to time based payment, I find it depressing that Medicare (and all other payers) cannot just accept physicians’ assessment of what he/she should be paid for a visit. I don’t think folks would just chat endlessly if the payment was time based. Lawyers don’t, and this is as easily audited as the insane E&M schemes.

Guest
rbaer
Sep 24, 2012

Do you have an idea for how many people seeing the provider is either a. a social outing or b. a situation associated with secondary gain? And of coursr its easier and more pleasant to see 10 patients and chat i/o 20 and rush from one to the next.

Guest
Sep 24, 2012

Yes, I do. I have seen elderly and lonely folks make appointments with PCPs just so they can talk to someone. The mostly geriatric practices where I observed this thought that was a nice thing to do (no, they weren’t looking for extra money), and so do I. Certainly beats antidepressants or worse.

I’m sure it’s more pleasant to see 10 patients thoroughly than it is to see 20 or 30 or whatever… I don’t see anything wrong with that either. Isn’t this exactly why Dr. Rob is stepping outside the system? If it’s so much better, why not make the system work that way too? Primary care is not that expensive….

Guest
rbaer
Sep 25, 2012

“I’m sure it’s more pleasant to see 10 patients thoroughly than it is to see 20 or 30 or whatever… I don’t see anything wrong with that either.”

As long as many people lack access to care, we have to use physician time wisely. In ideal world, agree that it would be nice to do your work without time constraints.

Guest
DrK
Sep 24, 2012

It is accounting software that has delivered on the ROI statements made by those selling EMRs. The problem is not the software or the doc using it, it is the way we are paid.

Let’s move these EMRs away from digitalizing a progress note and more towards population management tools which are in line with the new payment mechanisms being developed.

Guest
Sep 25, 2012

Reading this on the other side of the Atlantic is very strange. It seems that BIG BUSINESS has finally landed the coup de grace on the way you deliver healthcare out there. Finally doctors can work in the same way as accountants do. Every box ticked either manually or by default results in the reassuring CHING-CHING of the cash register. Doctors can now FEEL the money flow into their veins while actually practicing, giving them the necessary fillip to deal with the very important bureaucracy required by the professional accountants working for the all important insurance companies.

Alas, this technology will not improve your healthcare per capita rating in the world. The USA stands at 37th in the world (not bad not bad there are 100s of countries in the world you know) in this regard (If you don’t believe me read the NEJM of Jan 2010) with every chance of moving into the 40s. Still you do offer the ‘best medicine money can buy’ and as far as medicine is concerned, it is still the best place in the world to live – for doctors! As for the customers, I mean patients, well things are not quite as rosy but hey, blame that on your founding fathers: They were the ones who left universal health care out of the Constitution and for that they receive songs of praise from all your doctors, medical insurance companies and of course Big Pharma. But what can you do? Any alternative to this is communism, isn’t it?

Guest
Sep 25, 2012

Here’s an oncologist who likes the new technology.

This is just the beginning. Although EMRs now provide assistance with basic medical care, such as scheduling flu shots, identifying drug interactions, and health screening reminders, future systems will use academic information to assist the doctor in making diagnoses and planning treatments. Seamless with the EMR will be computer augmentation to create differential diagnoses and recommend treatment alternatives. In oncology alone there are almost 50,000 articles published each year; Artificial intelligence integration with the clinical EMR will help every doctor penetrate that massive database on a continuous basis as it applies to individual patients.

http://sunriserounds.com/?p=899

Guest
pcb
Sep 25, 2012

” Seamless with the EMR will be computer augmentation to create differential diagnoses and recommend treatment alternatives. In oncology alone there are almost 50,000 articles published each year; Artificial intelligence integration with the clinical EMR will help every doctor penetrate that massive database on a continuous basis as it applies to individual patients”

What percentage of those 50,000 articles are reliable studies that give us useful information that should influence clinical decision making? Are we hoping the “artificial intelligence integration with the clinical EMR” will help us sort that out by “penetrating the database?”
And what about patient preferences and values?

Garbage in……..

Guest
Sep 25, 2012

apropos?

“A culture of denial subverts the health care system from its foundation. The foundation—the basis for deciding what care each patient individually needs—is connecting patient data to medical knowledge. That foundation, and the processes of care resting upon it, are built by the fallible minds of physicians. A new, secure foundation requires two elements external to the mind: electronic information tools and standards of care for managing clinical information.

Electronic information tools are now widely discussed, but the tools depend on standards of care that are still widely ignored. The necessary standards for managing clinical information are analogous to accounting standards for managing financial information. If businesses were permitted to operate without accounting standards, the entire economy would be crippled. That is the condition in which the $2½ trillion U.S. health care system finds itself—crippled by lack of standards of care for managing clinical information. The system persists in a state of denial about the disorder that our own minds create, and that the missing standards of care would expose.

This pervasive disorder begins at the system’s foundation. Contrary to what the public is asked to believe, physicians are not educated to connect patient data with medical knowledge safely and effectively. Rather than building that secure foundation for decisions, physicians are educated to do the opposite—to rely on personal knowledge and judgment—in denial of the need for external standards and tools. Medical decision making thus lacks the order, transparency and power that enforcing external standards and tools would bring about.”

“… [C]urrent policy fails to comprehend the needed discipline in medical practice and thus fails to define precisely what is needed from health information technology. A dangerous paradox thus exists: the power of technology to access information without limits magnifies the very problem of information overload that the technology is expected to solve. Solving that problem demands a meticulous, highly organized, explicit process of initial information processing, followed by careful problem definition, planning, execution, feedback, and corrective action over time, all documented under strict medical accounting standards. When this rigor is enforced, a promising paradox occurs: clarity emerges from complexity.

No such relief from complexity is in sight now. A wide gap exists between current reform initiatives and the disciplined medical practice that patients need. This gap exists regardless of whether health care is public or private, and regardless of whether health care spending is provider-driven (traditional fee-for-service medicine), payer-driven (managed care) or now “consumer-driven.” Until the gap is closed, attempts at cost control and quality improvement will continue to revolve in a circle, without sustainable progress.

In contrast, were we to close the gap between medical practice and patient needs, society then could find enormous opportunities to harvest resources now going to waste. These wasted resources include not only vast sums spent on low-value care but also a vast body of medical knowledge that all patients and practitioners could use more effectively, simple tests and observations that in combination could uncover solutions to patient problems, patients who could become better equipped and motivated to improve their own health behaviors, routine patient care that could become a fertile source of new medical knowledge, and the firsthand insights of practitioners and patients who could participate in harvesting that new knowledge for their own benefit.
__

– Lawrence Weed, MD and Lincoln Weed, PhD, “Medicine in Denial”

Guest
Sep 25, 2012

Related:

http://healthaffairs.org/blog/2012/09/25/an-evidence-based-approach-to-communicating-health-care-evidence-to-patients/print/

“It has been 22 years since David M. Eddy—the heart surgeon turned mathematician and health care economist—put the term “evidence-based” into play with a series of articles on practice guidelines for the Journal of the American Medical Association.

But as we have learned in the years since, one person’s evidence-based guideline is another person’s cookbook. For some, a sound body of evidence is fundamental to sound medical decisions. After all, as Jack Wennberg and Dartmouth researchers have pointed out for decades, if the practice of medicine varies so widely from place to place in this country, everyone can’t be right. Yet for others, evidence connotes not just “cookie-cutter medicine,” it is only one step shy of a trip to the death panel. This heavy baggage influences the way evidence-based medicine is discussed from the doctor’s office to the clinic to Capitol Hill…”

Guest
Gwen
Sep 25, 2012

While technology is continually evolving, such as the advancement of EHRs, how it is utilized is up to the person. There are obviously many pros to utilizing EHRs – basic things such as providing efficient care in a timely manner and improving patient flow, whether it’s documenting by exeption, or using pre-filled templates. However, when used improperly, EHR does not serve it’s main purpose, which is to provide the best quality of patient care. Like Leo said, despite the advancement in technologies such as in health care, how they are utilized by health care providers is what really matters.

Guest
pcb
Sep 25, 2012

“A dangerous paradox thus exists: the power of technology to access information without limits magnifies the very problem of information overload that the technology is expected to solve. Solving that problem demands a meticulous, highly organized, explicit process of initial information processing, followed by careful problem definition, planning, execution, feedback, and corrective action over time, all documented under strict medical accounting standards. When this rigor is enforced, a promising paradox occurs: clarity emerges from complexity.”

I wish I had read this before. It’s all becoming clear…… clarity of patient care can emerge from complexity, if I just follow a meticulous, highly organized, explicit process of information processing, follwed by careful problem definition, planning, execution, feedback, and corrective action over time, all documented under strict accounting standards.

That sounds great. Sign me up.