THCB

Shock and Awe: EHRs Work as Designed

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.

Livongo’s Post Ad Banner 728*90

44
Leave a Reply

20 Comment threads
24 Thread replies
0 Followers
 
Most reacted comment
Hottest comment thread
18 Comment authors
EMR PilotMD as HELLGwenBobbyGpcb Recent comment authors
newest oldest most voted
John Ballard
Guest

Yesterday’s NY Times had a timely article by Dr. Kleinke, someone familiar to readers at this blog, The Conservative Case for Obamacare. A lot of what he says is germane to this discussion. The core drivers of the health care act are market principles formulated by conservative economists, designed to correct structural flaws in our health insurance system — principles originally embraced by Republicans as a market alternative to the Clinton plan in the early 1990s. The president’s program extends the current health care system — mostly employer-based coverage, administered by commercial health insurers, with care delivered by fee-for-service doctors… Read more »

Margalit Gur-Arie
Guest

I wonder, John, at point in the narrative did the problem of the uninsured became one of free-loaders devoid of personal responsibility. With few exceptions, people don’t have health insurance because they are too poor to buy any. Just because the Heritage Foundation declared it to be a personal responsibility issue, doesn’t mean it is so, and the fact that this administration adopted this rhetoric all the way to the Supreme Court, is extremely frustrating. Health care is just too expensive (and “shockingly” it seems that computerizing it is not making it any cheaper) and people are getting poorer and… Read more »

John Ballard
Guest

You’re right. Personal responsibility is a coded way of framing an argument which is really about individual versus collective responsibility. And the moment anyone speaks the word collective it triggers a visceral negative response beginning with “socialism” and ending with “lazy moochers.” It was bad enough before the election, but the Randian revival brought about by the likes of Paul Ryan and Ron Paul has made it toxic. In the last twenty-four hours I have come across three unrelated manifestations of that thinking. The anti-vaccination crowd is a large and growing threat to public health resting on that “individual responsibility”… Read more »

EMR Pilot
Guest
EMR Pilot

Margalit touches on one on the central issues with Meaningful Use. It was SOLD as way to help bend the cost curve (i.e. save money from duplicative lab tests, more efficient practice of medicine, etc.). To save billions of dollars more than it costs. Of course, we all know that it’s not gonna! But that’s what HIMSS, Allscripts, GE, Epic, etc. convinced bipartisan legislators and the Obama administration was going to happen. Remember when someone published an article citing that docs with EMRs order more tests than those without? The response from Farzad was tremendous. All of a sudden the… Read more »

Margalit Gur-Arie
Guest

Great pen name, seeing how people keep comparing health care to aviation.

Anyway, to your last point, my educated guess would be that the same small handful of inpatient EHRs and the dozen or so of full-featured ambulatory products that have the largest market share, are also the ones excelling at optimizing billings for their clients.

BobbyG
Guest

Yeah, Margalit. That’s the conundrum. But, I think you’re mischaracterizing the Weeds’ book just a bit. Yeah, the book is radical — almost utopian in some areas — but it has a lot more going for it than a lot of other stuff I’ve read, both in terms of argument and citation. In empirical reasoning, you’re always screwed. “n’ too small or unrepresentative? Anecdotal. “n” too large? Well, now you got the “sigma/sqrt(n)” problem of “statistical” vs “clinic significance” (one of my picks with this whole nascent “Big Data” lovefest). And, of course, the auditors, regulators, and lawyers ALWAY have… Read more »

Margalit Gur-Arie
Guest

I did not mean to imply that this was the essence of the Weeds’ book. I know it is much bigger than this and quite fascinating, at least for me…

We have ways to go before any of this is settled…. Stardate 5643.31….

MD as HELL
Guest
MD as HELL

You just keep getting better and better.

Margalit Gur-Arie
Guest

Should I be worried? 🙂

MD as HELL
Guest
MD as HELL

No

Margalit Gur-Arie
Guest

Regarding the Health Affairs article: I’m struggling with the label “evidence-based” medicine…. What is the alternative? Non evidence-based? Guess work? Making stuff up as you go? What is evidence? Is education or experience a type of evidence? Is there zero bias when other types of evidence are created? Is it possible to have conflicting evidence? Should all evidence be considered equal? Is new evidence better than old evidence? Always? Sometimes? Are we saying that all people would act in the same way, if exposed to the same evidence? Is professional judgement not required if we have evidence? Or is practicing… Read more »

BobbyG
Guest

Several decades ago, written by surgeon and writer Dr. Richard Selzer: “On the bulletin board in the front hall of the hospital where I work, there appeared an announcement. “Yeshi Dhonden,” it read, “will make rounds at six o’clock on the morning of June 10.” The particulars were then given, followed by a notation: “Yeshi Dhonden is personal physician to the Dalai Lama.” I am not so leathery a skeptic that I would knowingly ignore an emissary from the gods. Not only might such sangfroid be inimical to one’s earthly well-being, it could take care of eternity as well. Thus,… Read more »

rbaer
Guest
rbaer

I think the wikipedia entry may be helpful http://en.wikipedia.org/wiki/Evidence-based_medicine Yes, some doctors are operating more or less on what they have been taught (even though it may be out of date) or what they experienced (e.g. I tried intervention x for this patient even though it is not indicated – had great success and I will do this again – even though it may have been coincidence or placebo response). The problem of course is that there are many medical interventions that are not proven by EBM standards, but noone will forego these interventions/treatments and no double blind randomized controlled… Read more »

Margalit Gur-Arie
Guest

So basically, rbaer, you are saying that without some guiding entity sifting through various evidence and formulating their conclusions, individual practitioners are just not going to bother to stay up to date? Or are not able to stay up to date due to sheer volume? Or maybe that it is worrisome that folks may interpret evidence in variable number of ways, and it is better to have a single way of doing things?

BobbyG
Guest

A central conundrum of medical care is the relatively loose coupling of cause(s) and effect. If you have an adverse patient outcome, does it necessarily follow that you did one or more things “wrong”? Conversely, can you legitimately take causal credit for all of your good outcomes?

Asked and answered.

Margalit Gur-Arie
Guest

Well, I know that some folks have this vision of being able to collect a large number of data points from the patient, feed it to the computer, which will sift through mountains of “evidence” and based on some algorithms (programmed by whom?) will display a ranked list of differentials. This is the personalized EBM that Dr. Weed, I believe, is proposing. What if you pick, #2 because you think you know better and the patient is harmed? Are you liable for malpractice? Alternatively, what if you pick #1 and the patient is harmed? Are you liable precisely because you… Read more »

rbaer
Guest
rbaer

I don’t know … I can only say something about the care of patients who have seen other doctors (of my specialty or, to a limited degree, of other specialties) and docs I interact with. In general, EBM is on the rise (taught in all medical schools) and it may be in part a generational problem. I have seen doctors explaining nonsensical, non EBM stuff they are doing with a certain pride and reference to their expertise and experience. Some academic doctors like elaborate theories based on their knowledge of pathophysiology and biochemistry, but unfortunately, history teaches us that this… Read more »

Margalit Gur-Arie
Guest

I agree with your conclusion and I hope the “system” allows enough latitude for that to happen…

pcb
Guest
pcb

wait….., what, clarity, meticulous highly organized, complexity, information processing, problem definition, accounting standards.

what were we talking about again?

pcb
Guest
pcb

“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,… Read more »

Gwen
Guest
Gwen

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.

pcb
Guest
pcb

” 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… Read more »

BobbyG
Guest

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… Read more »

BobbyG
Guest

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… Read more »

John Ballard
Guest

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… Read more »

Dr
Guest

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… Read more »

DrK
Guest
DrK

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.

Margalit Gur-Arie
Guest

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… Read more »

rbaer
Guest
rbaer

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.

Margalit Gur-Arie
Guest

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… Read more »

rbaer
Guest
rbaer

“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.

Bobbi
Guest
Bobbi

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… Read more »

Margalit Gur-Arie
Guest

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….

Bobbi
Guest
Bobbi

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.

J.T.
Guest
J.T.

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.

steve
Guest
steve

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

rbaer
Guest
rbaer

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.

Margalit Gur-Arie
Guest

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.