Clinical Content Issues for the Third Party Biller By Ron Sterling linical content can make or break the EHR experience of your physician clients. Clinical content refers to the various checklists, documents, and C forms that address an area of medicine when using an EHR. For example, a pediatric practice would be interested in documentation tools for a newborn visit and age-appropriate well-child visits. An orthopedic practice would need site-by-site tools to document injuries and treatment. not all EHrs have clinical content for all areas of medicine. For example, some EHrs have clinical content for internal medicine, but lack the details needed for dermatology or cardiology. indeed, some EHrs are focused on a specific medical specialty: some products are dedicated to plastic surgery, while others are targeted at cardiology. Targeted products may lack the basic capabilities needed by other types of practices. A primary care-focused product may handle outgoing referrals but lack surgery scheduling tracking needed by specialty practices. The challenge for a third-party billing organization is that an EHr limited to a select area of medicine may require you to support more than one EHr in your client base. regardless of the type of practice, the adoption and use of EHr clinical content requires careful consideration and review. indeed, it is not the EHr vendor or even your third party billing organization that can validate the efficacy and appropriateness of the clinical content. As a matter of due care and professionalism, your client practice needs to carefully review and understand clinical content as a key feature of their EHr. A disturbing number of practices have failed to analyze the clinical content of their EHrs and are distributing exam documents and other information that do not adequately or accurately document patient care. in the more serious situations, EHr clinical documents misrepresent the care provided and the patient’s condition. For example, one practice was distributing exam notes that included inappropriate gender information for all patients. in another situation, a specialist included cardiovascular reviews of systems that were not performed and not the specialist’s area of expertise. The source of both problems was the use of clinical content setups that came with the EHr. The doctors just started working with their EHr’s clinical content without understanding what the clinical content represented and the presentation of clinical content to patients and others. Such problems could precipitate a wide array of care, insurance, and medical professional liability issues. These documentation errors and misrepresentations are a direct result of the nature of EHrs and how many practices initiate their use. As a practical matter, many physicians are concerned with the level of effort needed to complete documentation for a patient. With the best of intentions, many vendors offer extensive out of the box forms and features to speed adoption and documentation. For example, some EHrs generate an extensive note from a single “click.” Other tools allow doctors to cite forward information from a previous patient note, or bring in a standard note that documents what would typically happen with a typical patient. After the note is started with a citation forward or a note template, the physician proceeds to “chart by exception,” modifying the pre-prepared note to document a particular encounter. These strategies are analogous to the standard dictation templates that many physicians use with their transcriptionists. However, EHrs differ dramatically from transcription since many physicians and staff are not familiar with what is happening in the computer and how information is presented to patients. Sometimes, when a note is cited forward or a template note is brought into the patient encounter note, the physician does not necessarily see all of the information or findings that were added to the patient’s note. These out of sight findings may cover services that may not have been provided or may not be appropriate. For example, as doctors try to minimize clicks, more and more care may be added to the template, but the doctor may not have the time to check each finding to eliminate the items that were not actually performed. As importantly, many EHrs do not indicate which findings were brought into the note versus information that was entered 52 HBMA Billing • MArcH.April.2013
Billing_MA13
To see the actual publication please follow the link above