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Clinical Content Issues for the Third Party Biller
An article by Ron Sterling taken from the March-April 2013 edition of HBMA Billing.
Clinical content can make or break the
EHR experience of your physician clients. Clinical content refers to
the various checklists, documents, and 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 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, 2013.