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.