EHR issues by the doctor. one would have to review all of the screens and information without any indications of information that you have entered or even reviewed. unfortunately, many doctors do not check on the various representations that were inherited from a previous note or a template of typical findings. generation of exam notes and other documents can further obscure the physician’s intent. for example, many ehrs have scripts that pull information from the entered items and generate the exam note, referring doctor letter, disability certification, or other document. any change to the input of information or the script that produces the document could affect the presentation of information. for example, a change to the script could programmatically derive a statement that was not explicitly recorded by the physician. in cases where additional information was entered into the standard template, the practice would have to modify the script for the information to be presented on the produced document. otherwise, some ehr information would not be included in the printed note. Whether the practice is installing or using an ehr, your physician clients need to carefully evaluate clinical content before adoption and use. indeed, your work with your clients can lead to more effective use of the ehr that can produce better patient documentation as well as improve your support for billing and coding of services. consider the following action items to guide your physician clients: • VERIFY CLINICAL CONTENT – Physicians need to train on and verify the clinical content by patient problem or service before they serve patients. the doctors should practice with previous services and verify that they can document the patient service in addition to reviewing the representations on the printed documents. in some cases, physicians have discovered information on the note that was not the result of entered items, but was instead added by the script that produced the exam note. • MANAGE PRODUCTION DATA – in some cases, physicians have used test templates and obsolete forms to document patient care. staff and physicians need to protect the production database from any “test” templates or other setups that could be accidentally used to document patient care. indeed, practices should not mingle their production setups and scripts with any test setups. in your role as technology advisor, you can set up procedures to control changes to templates as well as work with clients to collectively identify improvements to clinical content and setups. • IMPLEMENT QUALITY ASSURANCE – doctors and staff need to check the letters and other documents that are being produced from the ehr. in many cases, the information is entered in the patient chart, but the note produced from that information is not reviewed. unlike transcription, the person generating the visit note or letter may be the only person from the practice who will ever see that document before it is sent to a patient or other healthcare organization. • REVERIFY CLINICAL CONTENT – changes to clinical content or scripts that produce documents should trigger a new verification of the clinical content and additional training for physicians and staff on the changes. ehrs can assist in the documentation of patient care and offer a wide range of benefits to physicians and patients. however, physicians and staff need to make sure that they protect and manage the clinical content foundation of their ehr as well as understand the implications of the clinical content on the documents that they produce. third-party billing services are directly affected by the quality of these notes and may have a better understanding of the quality of the patient documentation than the practice. guiding your physician clients in the use of ehrs and the appropriateness of the clinical content will help them take advantage of their ehr investment and help you more effectively work on their behalf. Ron Sterling (800-967-3028, www.sterling-solutions.com) publishes the popular EHR Blog Avoid-EHR-Disasters.blogspot.com and authored the HIMSS Book of the Year Award winning Keys to EMR/EHR Success. He is an independent EHR consultant. © Sterling Solutions, 2012 Billing Update! We are working hard to enhance Billing to ensure that it meets the needs of our membership, but need your input. as you see, each issue has been greatly expanded to include topics that impact our industry and businesses. do you have a suggestion for a future column in hbma Billing? is there a specific topic that you would like to see covered by industry experts? do you have any comments about past articles? Please offer suggested topics for Sound Off! as well. We want to hear from you at billing@hbma.org. the journal of the healthcare billing and management association 53
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