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Readers Write: Regarding the Nightmare on EHR Street

May 7, 2013 News 3 Comments

Regarding the Nightmare on EHR Street
By Frederica Krueger

I find it ironic that the AMA is complaining about the fact that physician documentation in an EHR is "pure torment." Perhaps they believe in the “Hypocritic oath?”

The reason for this documentation torment is the need to record multiple pieces of information that the physician asked or reviewed but that don’t end up contributing to the synthesis of the clinical picture or the plan of evaluation and treatment. Cluttering up notes with such information is often made worse by the formatting afforded by the EHR. It also detracts from EHR usability and patient safety.

The irony is that the underlying cause of this nightmare is the E&M coding system used to bill for clinical services.

And, that the E&M codes are part of the CPT system that is developed and sold by … the AMA!

The E&M coding system was cumbersome and inane long before EHRs became readily available. In the past, it was just too much trouble to document everything that you actually did to meet the E&M requirements and too hard to keep track of all the arcane rules. But everyone naturally assumes that a computerized system should help remind you of these confusing requirements and facilitate recording of the irrelevant info that was already needed for billing purposes.

With EHRs, there is a much greater focus on appropriate recording and coding at the physician level. It’s not surprising that physicians attribute the documentation horrors to the EHR rather than the CPT.

If the AMA really wanted to do something about the torment of EHR documentation, it would:

  1. Stop developing (and selling) the CPT manual. In other words, the AMA should put its money where its mouth is.
  2. Advocate for a common sense approach to determine whether physician documentation is or isn’t "fraudulent" rather than the current Checklist Menu approach.
  3. Recognize that most physicians are just trying to do right by their patients, and that they could do this much more efficiently — EHR or not — without having to deal with the E&M coding system. The crooked physicians will figure out how to scam the system anyway, so why waste time and money and frustrate the rest of us with E&M codes?

Despite the fact that I’ve gone for 30 years of medical practice without joining the AMA, I would sign up in a microsecond as a way of expressing my gratitude if the AMA eliminated (and got insurers and CMS to eliminate) all use of the E&M coding system.

While they’re at it, it would be nice to get rid of the RUC, RVUs and the RBRVS system, but that is less relevant to EHR torture per se.

Comments 3
  • It appears to me that in the early 1990s, someone was seeking to improve patient care. Many of these thought that better record keeping would help to assure same…back then, there was even talk of fines for illegible handwriting on patient’s records, and help in the form of handwriting lessons was even offered to the most in need. So it seems that electronic records was not even under consideration. Take a good long look at this excerpt from one of the master documents:
    Even though ‘very large portions of HIPAA practically rail against’ the manual recording of information and text this seems totally opposed to the governments’ imposition of very rigorous documentation standards for Evaluation and Management Services coding (1992) Those standards, which were at least partially the result of collaboration with the AMA, seem very much to encourage hand-written notes and even imposed penalties for illegibility! Although the government may not have been fully cognizant (sound familiar?) of what they were doing at that time, can anyone seriously doubt that this mentality aimed to ensure higher levels of quality healthcare by encouraging doctors to think more intensely about the care of their patients? (In fact, can anyone doubt that all collaborative efforts and actions of the AMA and the government are designed to ensure this? Besides, the close association of Big Business in this equation practically guarantees cost-cutting and other measures designed to solidify investor confidence! So how can we go wrong?) Insurance companies and government programs have also been known to reduce or deny payments in the case of missing or inadequate documentation and have gone so far as to actually consider undocumented services as not having been performed! (Since the US government (and all governments) effectively claim earthly divinity, is it possible that they also saw fit a need to promote more intense thinking and communication and learning via the written words?

    What we are forced to question is if the last supposition above is true (ie: that the leaders of the advancement of the principles of documentation thought that patient care could be improved via the process of doctors spending more time thinking about the care and condition of their patients and that by handwriting notes about those patients and their conditions would be more likely to promote such, why did they not stand up and protest when it became so clearly evident that the mechanical recording process would be made anachronistic?

  • It is a nightmare, but not because of the EHR. There is NO reason to and lots of reasons not to recapitulate patient data from the EHR database into a “progress note”. The purpose of a progress note is to report on progress not regurgitate. Some well intentioned compliance officers propagate the double myths that 1) pulling information from the database into the note without comment is equivalent to evaluating it and 2) if you evaluate information you must pull it literally into your note.

    Consumers of progress notes including people writing progress notes and reading other progress notes would greatly appreciate progress notes that simply point out the important normal and abnormal I/Os, labs, vitals and other information dredged from the database. The APSO format of the note (putting Assessment and Plan at the beginning and Subjective & Objective last) are a symptom of this malady.

    Notes that systematically walk through each problem addressed and comment succinctly and specifically on patient data for evaluation and management is all that is needed for proper reimbursement.

    The AMA could help by issuing that statement rather than dismantling E&M codes.

    Will Nightmare on EHR Street be happy when E&M codes and physicians disappear in ACOs that send teams of physician extenders and nurses to homes to give health care? Be careful what you ask for …

  • Good luck getting the AMA to drop CPT – they make $40-70m a year from the copyrights and it allows their primary drivers (the surgeons, et al) to continue to drive the payment process. The irony about the E&M codes is that they cause so much trouble, yet they are a fraction of the payment value of the 1000s of other procedures in the book. Add a centimeter to a laceration repair – new CPT code and more $$. Spend another 15 minutes talking to a teen girl about her eating problem – nada.

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