Our hospital finished the last year with an inpatient mortality index of 0.54, a fantastic accomplishment. That means that we provide great care and we play the documentation game well....
The electronic medical record was created to make it easier to practice medicine. But the unintended consequence of the EMR was that it made it easier for regulatory agencies to tack on additional documentation requirements. It is the documentation excess that doctors hate. But like Pavlov’s dogs, we’ve come to associate that documentation excess with the electronic medical record. At its core, the EMR is just a place to store information about patients, just like the paper charts kept in manila folders that we used 20 years ago.
A study of the use of the EMR in emergency departments found that the average patient encounter required 194 mouse clicks. In a typical office practice, that number is probably about half that – let’s just say 100 mouse clicks. But as we move further toward value-based purchasing and risk-adjusted billing models of reimbursement, the number of mouse clicks per encounter will continue to increase. Lets take a look at where all of those mouse clicks go. We’ll start with a hypothetical patient who comes to the office for a return visit to check his blood pressure. What you really need to document is: “BP = 154/94 on hydrochlothiazide. Will add lisinopril 5 mg/day. Patient also has edema; will check creatinine and cardiac echo. Return to office in 2 weeks.” If you look back at hand written charts from 30 years ago, that is exactly what the progress note would say and it would have conveyed everything that the doctor needed to know about for that particular encounter and the doctor would have billed for a level 4 return visit (on the 1-5 scale of return visits). But today, to bill that level 4 return visit, the doctor has to add more documentation and all of that documentation requires mouse clicks. Here is the additional work that is now required in order to complete the encounter:
- Documentation of at least 4 signs or symptoms in the “history” portion of the encounter to meet Medicare requirements for billing a level 4 return office visit – 4 mouse clicks.
- Documentation of 5 signs or symptoms in the “review of systems” portion of the encounter to meet Medicare requirements for billing a level 4 return office visit – 5 mouse clicks.
- Documentation of 1 additional element in the “past medical history” portion of the encounter to meet Medicare requirements for billing a level 4 office visit – 1 mouse click.
- Documentation of 12 elements of the physical examination in the “exam” portion of the encounter to meet Medicare requirements for billing a level 4 office visit – 12 mouse clicks.
- Documentation of a minimum of 3 problems in the “impression” portion of the encounter to meet Medicare requirements for billing a level 4 return office visit – 3 mouse clicks.
- Documentation of whether the patient is a smoker in order to meet Medicare value-based-purchasing requirements – 1 mouse click.
- If the patient is a smoker, documentation of whether or not smoking cessation counseling was offered in order to meet Medicare value-based-purchasing requirements – 1 mouse click.
- Documentation of a review of all of the patients medications in order to meet Medicare “meaningful use” of the electronic medical record – 1 mouse click.
- Documentation of a review of the patient’s medication allergies in order to meet Medicare “meaningful use” of the electronic medical record – 1 mouse click.
- Documentation of a review of the patient’s problem list in order to meet Medicare “meaningful use” of the electronic medical record – 1 mouse click.
- Documentation of a Medicare-approved diagnosis code with the order for the cardiac echo in order for Medicare to pay for the echo test – 2 mouse clicks.
- Documentation of a Medicare-approved diagnosis code with the order for the creatinine lab test in order for Medicare to pay for the lab test – 2 mouse clicks.
If you add all of that up, it is a minimum of 34 mouse clicks (plus a lot of additional keyboard typing of various words) to complete the encounter and none of those 34 mouse clicks really adds to the care of the patient. Clever physicians have developed work-arounds in order to avoid having to do excessive documentation.
For example, they will create templates for their electronic medical record encounters that have all of the documentation elements for “history”, “past medical history”, “review of systems”, and “physical exam” pre-populated in their encounter note based on a typical normal patient, after all, the only person who would ever really look at all of that information is a Medicare coding auditor.
Other physicians will use strategies in the electronic medical record to automatically import information like the medication list, problem list, and allergies that had been previously entered into the electronic medical record during previous office visits – this results in long tables of data in the progress note with the result that the note is virtually unreadable to the clinician but has all of the necessary elements for the Medicare coding auditor to count.
Medicare requires all lab and imaging tests to be associated with a diagnosis and each test has a limited number of diagnoses that Medicare will accept in order to approve that test for payment. So, for example, Medicare will pay for a chemistry panel test for a diagnosis of “high risk medication use” but not for a diagnosis of “asthma”. On the surface, this sounds reasonable. But in practice, this can drive physicians crazy when they have to enter three or four diagnoses for an ordered test before they find one that Medicare (and therefore the electronic medical record) will accept for that particular test. Clever physicians have discovered diagnoses that can be used as “universal keys” to unlock the orders for commonly ordered tests – for example, the diagnosis “unspecified dyspnea” will work for just about any common lab test as well as an EKG, cardiac echo, chest x-ray, or pulmonary function test. Therefore, physicians often put “unspecified dyspnea” as a diagnosis, regardless of why the patient is being seen, just so Medicare will approve the test that they ordered.
The frustrating thing about documentation requirements is that regulatory agencies are always adding new requirements and they rarely if ever take away old documentation requirements. In other words, the number of mouse clicks per patient encounter grows each year, instead of shrinking each year.
A typical physician will schedule return patient visits in the office every 15 minutes. That means that they have 15 minutes to take an interval history from the patient, do a physical examination, review test results, counsel the patient, document the encounter, prescribe any medication refills, order any new tests, send a letter to the primary care physician, and complete the bill for that encounter. As the documentation mouse clicks add up, the physician has 2 choices: either extend the time for scheduled return visits to 20 minutes or reduce the amount of time spent talking with the patient. The net result of extending the encounter time to 20 minutes would be to reduce by 25% the total number of patients that can be seen in a day – this is not a viable option if the physician wants to stay in business. Therefore, each extra mouse click comes at the cost of a few seconds of time that would have otherwise been spent talking with the patient.
So, next time a doctor tells you that he or she hates their electronic medical record, what they really mean is that they hate all of the excess documentation that they have to do with the electronic medical record. It’s like of like hating pencils because you have to use them to fill out your IRS tax forms each year.
October 4, 2017