Streamlining EHR Documentation for the Patient-Provider Encounter

January 8, 2016

Improving EHR documentation will be an essential way to combat the recent trend of upcoding that has gotten the attention of the federal government.

A recent e-mail from my biller highlighted concerns from the Office of Inspector General (OIG) that there has been a significant amount of “upcoding” since the implementation of the electronic health record (EHR) and the significant growth of the electronic healthcare system.

Due to this concern, the OIG is encouraging the Centers for Medicaid and Medicare services (CMS) to begin auditing records, especially those of providers who consistently code their evaluation and management (E/M) visits at a consistently higher level than their peers.

It is possible that one of the reasons for the uptick in coding is the result of the ease of the EHR in “cloning” a record, in addition to EHR productivity tools such as cut and paste and keyboard macros  -software that will allows providers to hit a sequence of keys on a Mac, replacing the sequence of keys with text designated in the software.

Part of me ascribes this to how cumbersome many of the original EHRs were in allowing the provider to quickly and efficiently generate a unique narrative. The design of  EHRs from five years ago was more focused on meaningful use criteria and not on assisting the provider in accurate and fast documentation of the provider-patient encounter.

The OIG estimates that the failings of the EHR contribute to about $75 billion to $250 billion in annual healthcare fraud. It is obvious that both the government and the third-party health insurance industries are going to invest significant amounts of money into combating this fraud, and we will see many more audits of providers that fall out of the “norm” for E/M billing.

Tools are currently in development to look at serial healthcare records to determine similarity and evidence of cut and paste and cloning of previous records. However, looking at the experience of providers in my facility, we are at a stage now  where chart notes are voluminous, with a lack of a unique and concise narrative that reflects accurately the findings and recommendations of the provider making the encounter note.

We have infinite tools for incorporating seemingly endless information into our chart notes, but need more training about how to winnow that information down to what is pertinent to the current encounter.  We must learn to blend the time-honored tradition of the provider narrative that tells the story of the patient’s treatment and our response to treatment in a manner that is concise, accurate, and easy to understand.

How did we get here? That is a complicated and inter-related question.

• The EHR, especially in the inpatient environment, is exceedingly complex and not user friendly.

•  We still have significant generations of providers in our healthcare system with varying discrepancies in computer skills, some born with skills and others acquiring skills faster than others in some instances.

• Lack of streamlined EHR training - we need more and in a more efficient way. For example, while we are not quite there in training, providers have also been resistant to spending the time to be trained as they see it as a loss of productive patient care time.

• EHRs, up until the present, have been designed to satisfy the data gathering needs of the healthcare system, and not the encounter documentation needs of the providers.

Healthcare systems have been slow to recognize these problems, and it appears that additional challenges might appear (such as investigations and audits) as we transition to the full integration and implementation of the EHR in our inpatient and outpatient healthcare systems.

However, it truly behooves providers to understand how the EHR is misused, so that they can not only avoid the pitfalls and legal challenges of using the EHR in an inappropriate way. More importantly, in order to generate meaningful, accurate and elegant notes that get back to the tradition of documenting the patient encounter, and the course of their treatment in a manner that is easy understood by all who review the record of the patient. Bridging these gaps will further streamline the patient-provider experience with the EHR - which is truly an evolving one as this experience is so new.

Some recommendations to streamline EHR coding and usage:

• Never clone complete records. This function should be eliminated from the EHR. However, copying forward things like past medical history, review of systems, etc., is a time efficient function, as long as the provider actually reviews, and updates this information in the current note.

• Always create a unique history of the present illness, physical examination and treatment plan at every encounter. This is facilitated for providers at all levels when medical dictation is provided within your EHR.

• Learn how to pick and choose what information (e.g., ROS, past medical history, social history, labs, diagnostics) is auto-populated into your document template to keep it to the data pertinent to the encounter record.

• Be leery of “macros” except at the most basic level, for the same reasons as cloning. I still use macros for standard informed consent, etc., but make sure that it reflects the work done, and is customized to the patient. Each patient is different - and specificity is key.

The future is here. As providers we need to be aware of the pitfalls and challenges of the EHR so that we can apply what we have learned towards accurate and meaningful documentation of the provider-patient encounter.