January 18, 2016

Why Physicians are Liking EHRs Less and Less

By

The federal mandate for conversion of medical record-keeping to a purely electronic format for the purposes of developing statistics and its associated tracking of quality of healthcare delivery and billing for services (known as value-based purchasing) is virtually complete in the United States. 

Most hospitals and large physician groups are there, smaller ones are on the way to being there, and individual practices are all over the map.  Yet the two things that were never addressed in the initial implementation were the patient and the physician. 

Are you kidding me?

I have been discussing the documentation of diagnoses for each patient as being a valuable endeavor with thousands of physicians across the country. When we were working with paper records, it made sense to the physicians. It made sense to the nurses who cared for the patients. It made sense to the case managers, utilization reviewers, billers, quality team and revenue cycle folks; and all was well.  Then they made it better. And we made it electronic – digital.  

Nobody Knows what’s Wrong with the Patients 

Daily notes, whether compiled in the office or in the hospital, must be made using templates and different pages and different tabs, and “oh, it’s so much better because all you have to do is copy and paste.” And physicians are running all through the records to find pieces to insert into today’s note – so they copy every single progress note and consult ever generated and paste them into this note – and they copy every single lab test over the past five years and insert it into the note – and they copy every single radiographic study performed since age 2 and they paste them into the note – and they copy the diagnosis list, which includes everything the patient has had since birth, and they paste it into the note. 

All the while nurses in critical care units are screaming, “help us – we don’t know what wrong with our patients!” And the quality folks don’t know what is good and what is bad and when the heck it happened in the first place. And the care managers and utilization review people have no idea what’s current and what’s not and what they have to do for the patient to prepare for discharge. And the coders are totally lost. And billing depends on the coders.

Yeah, great advance.  

And don’t forget that no electronic record talks to another, so if the patient goes to another hospital or to another physician’s office or across the hall from the clinic to the X-ray department, nobody knows why the patient is there. We were promised decent inter-communicability – and some of the electronic health record (EHR) vendors are screaming that they don’t want this because it’ll hurt the bottom line. And nobody cares about the patient. So we wind up with the patient having exactly the same list of diagnoses at the time of discharge that they had when they were admitted – and the same list of diagnostic entities that were treated 16 years ago – but they never leave the diagnosis list.

Diagnosis Tools Talk Another Language 

At the end of every interaction with a patient, the provider must identify a diagnosis or list of diagnoses that will go to the patient’s database and be used for the provider’s billing for services. So the EHRs have these wonderful add-ons of ICD code helpers. But they don’t talk doctor – they talk coder language. And again, there’s no inter-communicability between coder-speak and doctor-speak in virtually all of them. There’s help available if you’re a coder taking care of the patient, but nothing directing the doctor’s choices in a manner understandable to a clinician. Why? Because the companies that developed these pieces of software had one source of information for their diagnoses – their problems lists – plus the ICD index and tabular lists. And again, they don’t talk doctor. And they lead to bad choices if given to someone who hasn’t taken a six-month course in coding on top of undergoing 6 to 12 years of medical training. I mean, what else does a physician have to do other than spend six months learning coding and another month or two learning how to navigate the maze of the electronic record and the coding tools therein? 

For example, a heart failure patient may have end-stage HFrEF (heart failure with reduced left ventricular ejection fraction) due to terminal hypertensive cardiomyopathy. And the doctor tries to enter HFrEF – and gets nothing. We have to approach it another way, so we enter CHF. And we get I50.9 – but we were told to never accept an unspecified code, so we try something else. So we try failure – and get a list a zillion entries long – so we add heart – and we get a shorter list of acutes and chronics and systolics and diastolics and no help with definitions. So we guess. 

And let’s move on to the cardiomyopathy. Try entering that – no hypertension in that list at all. We see dilated, so we guess that could be okay. And nobody knows that it was hypertension as the cause. And end-stage – fuhgettaboutit. Ain’t there. All we get is kidney disease. If the precise words are not delivered to the computer, the answer cannot be determined, period. By this point the doctor has spent more time trying to find codes for the patient’s visit than was actually spent with the patient! And the data that comes out is wrong.

Potential for Fraudulent Billing 

Physicians used to see a patient, tell the patient that the visit cost $15, and then the patient paid and it was over. We used to know that we would have to pay about $300 for an appendectomy – and it was over. Then insurance companies and Medicare came along. And the American Medical Association came up with standardized levels of payment to doctors of different specialties dependent on where the doctor saw the patient and in what city in which state.  

Now, with the electronic health record, we see that a doctor can put 12 pages of junk into each daily visit – and isn’t that worth a lot of money? So they bill a high level of care for an ingrown toenail.  

But critical care doctors see a patient on a ventilator and look for an ICD code and find respiratory failure – no, ACUTE respiratory failure – no, acute HYPOXEMIC respiratory failure – no, POST-OPERATIVE acute hypoxemic respiratory failure. And they bill critical carefor a patient who is being reversed from anesthesia for 15 minutes, who is quite stable after an elective left hip replacement. 

It’s so easy to take the resident’s note and the consultant’s note and copy/paste all of them – and, heck, why do I even have to see the patient?

This is happening, believe it or not. 

Doctors would love to go back to those thrilling days of yesteryear when they saw a patient, wrote a note, communicated with the primary doctor, and billed and got paid for services. It was so easy. Now, we have electronic health records here to help us get through the day. Baloney! More and more, physicians are realizing that they spend more time with the computer than they do with their patients, but the patients still want to see them. Physicians are seeing that others are doing things weird and are unhappy about it. Billers are seeing denials, both in the physician office and in the hospital. CFOs who were promised decreases in staffing are having to double their staff to get AR days down to where they used to be. You know, before things got “better.”

It was an incompletely conceived process that could have worked if rolled out properly, tested properly, and utilized in a test environment until all the bugs were eliminated. But that didn’t happen – and doctors and patients are suffering for it. And CFOs are learning little by little that the bloom is off the rose.

The emperor was persuaded that the new clothes would be fabulous – and they’re just not there.

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Robert S. Gold, MD

(1942-2016) The late Robert S. Gold, MD, was a nationally known physician, responsible for having championed clinical documentation with a peer-to-peer educational approach in hospital organizations. Dr. Gold was a cofounder and the CEO for DCBA, Inc., a consulting firm that concentrates on development of Clinical Documentation Improvement (CDI) programs that aid in proper data streams, proper communication within the medical records and proper reimbursement. Dr. Gold served on the ICD10monitor editorial board from 2011 through January 2016.

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