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The relationship between EMR and physician documentation [PODCAST]

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In this episode, Cyndy Kowalski, a manager in our Compliance Services Team at BESLER Consulting, discusses the relationship between EMR and physician documentation.
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Michael Passanante: This is Mike Passanante. Glad to be back with you here on the Hospital Finance Podcast. Today, I’m joined by Cyndy Kowalski who is a manager on our Compliance Services Team here at Besler Consulting. Welcome, Cyndy!

Cyndy Kowalski: Thank you, Mike! It’s good to be back.

Mike: So, Cyndy’s going to walk us through use of the electronic medical record with regards to physician documentation and whether or not that is a friend or a foe of the physician.

So, Cyndy let me put my first question to you. Describe for us how the electronic medical record evolved.

Cyndy: The electronic medical record is considered the next step, if you will, related to technology and the continued progress of healthcare. The intent is that it would strengthen the relationship between the patients and the providers or the clinicians.

The data, the timeliness and the availability would enable the providers to make better decisions, if you will, and actually provide better care.

Basically, the record is an electronic version of the patient’s medical history that is maintained by a provider over time. It may also include administrative data, clinical data and demographics. It could encompass office notes, progress notes, and surgical procedures.

It basically automates access to all of the information that one would require to care for a particular person.

Mike: So, we opened up the podcast by asking the question, “Is the electronic medical record a friend or a foe of the physician?” Can you tell us why?

Cyndy: Certainly. There are many valuable assets to the electronic medical record, but the path to get here has not necessarily been without its challenges.

I think one interesting note is that the EMR itself, the electronic medical record, is usually created by non-clinicians. And most often, there is not necessarily a lot of clinical, or more specifically, provider input. And I would suggest, most likely for a variety of reasons, changes made to the software are generally challenging. Sometimes, they can be expensive.

When it comes to some of the challenges, or the foe aspect, there are times it’s difficult (if at times not even possible) to even customize your document and customize your program. There just isn’t a way to do that.

In addition, when we think about the negative aspects, certainly bringing the physicians onboard and training them has been a challenge. When you think about changing the behavior of physicians who like many baby boomers have only recently become tech-savvy and now midstream or maybe even at the end of their careers, we’re changing the rules and we’re putting in all these systems, these checks-and-balances in computers with laptops, it’s a significant cultural change. And I believe that is still continuing.

Now on the other side of that as far as the positive or the friendly aspects is the ability to actually access information real-time. You can literally go into a patient’s record at any point in their care. You could look at the transition. You could improve the transmission of care.

Also some of the benefits, it leads to reduced errors whether through order-entry or documentation type of entry. It has the opportunity to support with a variety of tools, some clinical decision-making.

And certainly as we’ve talked about in many other podcasts, we finally can get away from the legibility discussion. It certainly makes the electronic stamps with the physicians’ identifying information a lot easier.

There is a lot of interface with other programs, labs, radiology. All of these will then meld into one final document.

So, again, it depends on how you look at it but there certainly are both positives and challenges with the electronic record.

Mike: Let’s talk about how the EMR can help physicians with regards to documentation.

Cyndy: First of all, I’ll mention it again, will be legibility. It certainly is a significant opportunity to do a more comprehensive review of the documentation as it relates to orders, medical decision-making and medical necessity (why the patient is actually in the hospital).

It also helps the physician on the post-discharge plan. It helps perform that transition if a patient is going to a home health or a SNF, there’s access then to that record. Or if a patient is being received from another skilled nursing facility, that information potentially can be transferred and open up a whole new opportunity to gather some additional data to assist in that clinical decision-making.

I think that it also will improve the coding and the billing. With a good, solid software program, you can avoid the inquiries that we’re sending to the physicians to clarify documentation to request to answer questions. It’s easier to find and track. So I think there’s opportunity there and it’s certainly assigning the code and actually getting the claim out the door is benefited by having everything right there.

Mike: Cyndy, what are some of the challenges you’re seeing with physicians and EMR?

Cyndy: Some of the challenges, I think, is this a friend or a foe as far as the physicians go? As the electronic record has evolved, we see the utilization of templates. They’re self-populated fields or auto-populated. We also see the use of drop-down menus and checkboxes for example.

And again, in and by themselves, they’re probably not necessarily always a challenge. However, when you self- or auto-populate, you have to be sure that the information being populated is accurate.

When you’re provided a drop-down menu, will that menu give you the opportunity to expand on something? An example we’ve talked about in another podcast is during the examination of a patient where you have an opportunity through a drop-down menu to say, “This is normal or abnormal” or with a check box.

There’s additional information that may be required. So I think with the use of the templates, the drop-down, to the check box – the challenge there is not providing all of the information that you may have available, limiting that.

I think another challenge is the use of free text. I think a lot of physicians don’t mind not having the ability to free text. Although we find then that the physician doesn’t have the opportunity to personalize to really add the additional information and the additional data points that were utilized. And I think something is potentially missing if you don’t have that opportunity.

Another challenge (and we’re starting to hear more and more about it and we’re starting to see more and more about it as we do our coding audits) has to do with copying and pasting and cloning. So that, too, can be a significant challenge.

And some additional challenges have to do with – it’s basically called Make Me the Author. It’s difficult to then track who actually wrote this. Was it the attending, the resident, the consultant or another provider? So those are some challenges.

These all are starting to become more and more apparent as electronic records are becoming – obviously, more and more organizations are getting them. More and more physician practices are becoming electronic.

And another challenge, as it relates to coding and billing, would be the practice of documenting for the sole reason to meet the higher level of service. This is also known as upcoding. Again, it’s important to remember that more documentation doesn’t necessarily mean better care.

Mike: Cyndy, I want to back up for just a minute and touch on something that you said earlier. So, can you describe for us, what do you mean by copying and pasting and cloning?

Cyndy: Absolutely! Copy, paste, cloning. Basically, they can actually be used as synonyms. What that means is that you’re literally taking the wording from one document and you are copying and pasting it into another patient’s record in the exact, same form.

We know now when we’re working on word documents, and we’re developing word documents, it’s very easy. We’re all familiar with cutting and pasting, copying and pasting. And it’s basically carried through the electronic record where, for time management reasons, we see a lot of taking a history in physical and moving it over or taking the past medical history and moving it over.

Some of the findings when we’re performing an audit, you will see that in the review of systems that some of the items are specifically related to a female versus a male. Or you mentioned that in the past medical history is pertinent to an elderly patient versus a child or an adolescent. And that is more of the obvious, that kind of stand out, but there are some that don’t jump out at you right way.

The challenge with that is, “How do you not do it?” It’s okay to use certain verbiage to move over but when you’re moving the entire component of what you’re doing, that’s when there’s a problem. And that is becoming more and more apparent as we go through some of our audits.

Mike:  How can you address some of the challenges we talked about here today?

Cyndy:  I think one of the first things is the documentation that is placed into the record should actually fit the visit. If the patient comes in with a problem-focused complaint, we’re going to do a problem-focused history. The documentation should fit that. We shouldn’t necessarily see a complete review of systems or complex decision-making when the patient comes in with something such as that.

As I mentioned, there are opportunities where you can certainly use statements or certain testing where you can actually copy and move it over and paste it. But we should not be seeing copying and pasting of the entire note. Again, everything in moderation.

All notes that are entered into the record should be personalized to that specific patient. The note should not talk about an elderly female. It should be as specific as possible (e.g. a 72-year old white female, well-appearing) – again, all of that personal information that we used to see with handwritten documentation.

And I think another aspect is that the documentation must support the code that’s being utilized. If this is a new patient, a new visit or established, the documentation should support that, just as I mentioned, it should support a problem-focused exam.

In addition, auditing is another way to perform a baseline to validate corrective action but also to support ongoing performance metrics. If you’re acquiring a physician practice, and certainly on a routine basis (whether that’s quarterly, twice a year, sample size, maybe 10 records are monitored), that can be part of information that can be used for credentialing reappointments. You want to make sure that it’s an ongoing process.

Mike: So how do these things become a problem or problems?

Cyndy:  I think that these items all become problems when (1) there are no parameters established. If you, as a practice or organization do not have policies and procedures, perhaps that say, “We do not copy and paste. This is the template that we use.” I think that’s really the start of that.

In addition, I think it’s important when you think about becoming a problem when the organization first decides to implement an electronic record. Do you have all of the key stakeholders involved? I mentioned earlier generally, there are no clinicians and certainly we see that changing over time. But getting physician input, getting physician buy-in, I think is important as it is across the whole organization. So I think that certainly could mitigate some of those issues.

In addition, I think the education and training certainly implementing a major software conversion is significant but I think the education and training to support that is imperative with the follow-up. How is everyone doing with this? And this may not just be the providers. It could be any type of clinician whoever is in the medical record.

I think there’s opportunity across the board: order-entry, documentation, consultant notes and things like that where there is opportunity to monitor it. Again, especially if it’s a new conversion, to be sure that there isn’t a learning curve that more education may need to be required.

And I think, in addition to that, having an understanding of where people are in this age of technology, we certainly know that the younger people will use every type of device and be able to navigate.

I don’t think it’s necessarily the best way to assume anybody can pick this up. If a physician has never had an electronic medical record in their office and are not necessarily using laptops or computers at home or at work, I don’t think you can assume that it will be easy to pick up.

There’s a lot of data that need to be collected, then it needs to be analyzed. When you think about the interfacing with these electronic records, they’re going to need to pull information from radiology and from lab interfaces. Maybe they even have to pull information from an ED record or critical care record, because they’re on different systems. I think that you can’t overemphasize that enough.

I think it really needs to be an intrical part of the selection, to make sure there’s input. The development and implementation of the record and then the auditing and monitoring to be sure that you have all the updates that are necessary. People are trained and then you’re monitoring and auditing to make sure they are being used effectively but more importantly, compliantly.

Mike: Cyndy, thanks for shedding some light on EMR and how it relates to physician documentation.

Cyndy: Thank you, Mike.

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