Who said the road to EMR documentation compliance would be easy?
Wednesday, April 08, 2015
I am a registered nurse, but my official title now is regulatory analyst. Like many clinicians, I began my career in the hospital. Along the way, I veered from a clinical focus to regulatory compliance.
I moved to case management, which led to quality assurance and utilization review. Here I was faced with the task of understanding healthcare documentation in a new way and determining if it was in compliance with myriad regulations.
Intrigued by technology and a belief in the digitization of healthcare, I moved into the private sector and began working with creators of data and healthcare information management systems. I learned quickly how IT architects and builders approach a project — these are numbers guys who think mathematically and logically.
I recall working with a talented developer to create a tool that mirrored a claim form. When I explained the required claim fields, he told me repeatedly, "That's not logical."
I tried to explain a major dilemma in healthcare — the clash between clinical documentation and reimbursement requirements. There is quite a chasm between how clinicians view medical record documentation versus billers and payers versus compliance auditors.
From the clinician's perspective, a medical record is more of a note to themselves or other care providers, a reminder of the patient's condition on a particular date. I've seen clinical notes for inpatient hospital visits that said nothing more than "unchanged" — no signature, no orders.
As a clinical nurse, I knew that documentation meant no change in orders. As an auditor, I was looking at the same information through an entirely different lens.
The auditor's perspective
Compliance auditing focuses on different perspectives: Does the documentation support the care provided? Which reimbursement (CPT, HCPCS, ICD) codes can be assigned to the encounter based on the medical record? Does the documentation comply with medical record-keeping standards?
Initially, I was excited by the idea of electronic health records (EHRs) — finally, legible notes! I thought my job would be easier, until I began to actually read the documentation in the EHRs.
Medical documentation for a patient visit is known as an evaluation and management (E/M) service. In order to be reimbursed, a healthcare provider must document specific components of an E/M service. These include a chief complaint (what in the patient's words is the reason they are seeing the doctor), a review of body systems, a physical exam, an assessment of the findings and a plan of care.
Below is a real-life example of documentation I have witnessed in EHRs.
The chief complaint for this patient's visit to a healthcare provider was "low back pain." The documentation in the EHR goes on to recount every bit of historical data possible about this patient. OK, just being thorough, but it also says the patient has influenza? Interesting, the patient made no mention of having flu symptoms.
Review of systems (ROS) follows the chief complaint and history. The provider documented that all systems were negative including musculosketal. Wait a minute, this is a patient with low back pain — the ROS should be positive for low back pain!
The exam documentation follows the ROS. Again, everything is normal. I should see a positive neuro exam or a positive exam of the extremities or the back. Does this mean the chief complaint is wrong or the exam is wrong? Low back pain is a pretty straightforward complaint.
The final entry in the EHR is the physician's assessment and plan of care. In this instance, lumbar spine X-rays are ordered, followed by an MRI. Wait a minute! Money is going to be spent on diagnostic intervention for a patient who allegedly has low back pain but then has a perfectly normal review of systems and examination? How can this be? Or is it possible that not only the ROS data was cut and pasted, but the exam as well?
It turns out that the influenza diagnosis was documented six months earlier when the patient actually had flu symptoms. Because the history was cut and pasted from one visit to the next, the diagnosis was dragged along with every subsequent encounter. According to the medical record — a legal document — the poor patient had flu for six months.
The information is just about useless since the data is in direct conflict. It's impossible to ascertain if this patient received any benefit from the encounter, but the healthcare provider was reimbursed for what appears to be medically unnecessary and substandard care.
Who created an EHR with the ability to clone inaccurate data? Remember those architects and designers? It is logical to allow the user to move data from one document and place it in another — saves time, right? Maybe, but not so much in healthcare since it also creates errors that could be detrimental to the patient's health.
In addition to the possibility of adversely impacting care, the data gathered from the EHR system is inaccurate. Garbage in, garbage out, as the saying goes. Finally, the time-saving effect of indiscriminate movement of data also impacts healthcare reimbursement values (time spent with patients is a consideration in reimbursement assignment).
I've asked myself repeatedly, how did this happen? Were clinicians not consulted during the development of EHRs? Were health information management professionals avoided since they might offer rules that are complex?
What happens when a payer audits documentation like this? Likely a claim denial since there is no evidence that indicates the patient required additional intervention.
Data practices that work in the rest of the world do not necessarily work in healthcare. An individual's financial history is black and white — it doesn't change. But healthcare history is an evolving, morphing data set that must be treated carefully.
Electronic medical records are superior to the handwritten variety if for no other reason than their legibility. But that is not enough. My hope is that the next iteration of EHR builders work closely with clinicians, healthcare information management professionals, compliance folks and patients. Each has a stake in getting it right from their own unique perspective.
And since the same data is required for such varying uses (clinical vs. reimbursement vs. scientific), it's essential that all stakeholders have a seat at the proverbial table.
I know it will be a challenge. It will be even more complex. And it likely won't be logical.
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