This article also appears on RACMonitor.com

We find ourselves at the dawn of the era of the mandatory electronic medical record (EMR). While the technology holds the promise of simplicity of integration and coordination of care, I am beginning to see that creating a medical record that makes sense to an auditor may become a longer road than physicians are anticipating.

In my role as a physician documentation auditor, I am learning that the term “meaningful use” is applicable more to an oblique government standard, and not so much to documentation of a patient’s illness. This year I have conducted documentation reviews for physicians in clinical and hospital settings that have proven this thesis in bold and uncomfortable terms.

In one case, I had a physician who, as part of their examination template, utilized the term “average stature” on every sample submitted for review. The range of patients reviewed in this case went from a 140-pound female to a 397-pound male, which by any measurement would be a rather inclusive definition of the classification of “average”. In another case, we had a hospital-based physician group who was utilizing an EMR for their particular patient base. In more than one case, specific laboratory test results were indicated as pending several days after the desired result was noted in the medical record.

Both of these examples point to the biggest problem with EMR implementation, which is best described as “build what makes you comfortable”. Too often, when training physicians to utilize a new EMR, adequate time to prepare the doctor for its best use simply isn’t available. To combat the time crunch, the trainer, in concert with the physician, assists in building a patient encounter template that represents the most-likely patient to be encountered, rather than one that has the ability for adjustment based on the presenting symptoms of the patient.

This problem is exacerbated by coding consultants who are quick to offer “phrases that pay”, and far too slow in counseling the physician on documentation and code selection focused around medical necessity. This leads to language in typical examination documentation that is in opposition to itself from paragraph to paragraph and, more importantly, doesn’t provide a clear picture of the patient’s actual health status. What at first appears to be a well-organized EMR template built for physician simplicity quickly morphs into the appearance of “cloned” documentation across many patients, which in turns increases audit risk.

With regard to physician documentation, the recovery auditors have thus far focused their attention on plans of care by admitting physicians in the hospital setting. As a result, hospitals in turn have turned to clinical documentation improvement (CDI) to remedy shortcomings identified by the auditors. One wonders whether the timing of CDI programs is accidentally premature, given that newly-implemented EMRs have the potential to reopen Pandora’s Box as hospitals acquire physician practices in advance of the Accountable Care Organization model.

Physicians in private practice have yet to feel the full force of recovery audit efforts to find improper documentation, and CMS has stated in the past that they will alert physicians nationwide when Evaluation & Management services are about to be audited. There is a significant difference with this population of doctors however, as they tend to exist without a training infrastructure to assist them in fine-tuning their electronic documentation. A great many physicians not affiliated with large institutions find themselves at the mercy of either their office staff or of outside consultants of varying quality who do not carry minimal emotional investment in the physician’s best interests.

The proliferation of EMR systems can be seen as a chance to either seize or be seized by opportunity. Choosing a specific electronic medical record for your practice should not simply be seen as a way to make a quick buck. In selecting an EMR for implementation, physicians should do their level best to block out the voice of the salesman promising thousands of dollars in Meaningful Use dollars, and select an EMR that will allow for flexibility based on the range of patients seen by the practice. Any and all vendors should be quizzed carefully as to training expectations and end benefit to your practice. In addition, physicians should enter a mindset that learning how to use your EMR never ends. This would be very similar to recovery auditors being on their never-ending quest to seek out improper payments based on deficient documentation.

Tags: EMR / Recovery Auditor
8:35 am, September 1st, 2011 |