Category: Electronic Medical Records

Categories
Electronic Medical Records Outpatient Practice

Why The Medication List In Your Electronic Medical Record is Wrong

The importance of an accurate medication list for every outpatient cannot be overstated. In theory, the electronic medical record should improve the accuracy of the medication list but in reality, medication lists are very often inaccurate. The act of verifying the medication list is called “medication reconciliation” which sounds so easy on the surface but is so hard in reality.

The Agency for Healthcare Research and Quality (an agency of the U.S. Department of Health and Human Services) says that there should be a single medication list that is the “one source of truth” for the patient and that medical practices should standardize and simplify the medication reconciliation process in order to make the right thing to do the easiest thing to do. But in most outpatient practices, mediation reconciliation is neither standardized, simple, or easy. Pull up any patient’s electronic medical record and if that patient sees more than 1 physician, there is a pretty good chance that the medication list is not accurate. Here are some of the reasons why:

  1. No stop date on short-term medications. Recently, I opened a patient’s chart and found that the medication list included amoxicillin. I asked the patient who said she wasn’t taking amoxicillin. So I pulled up the medication history and found that she had gotten a 7-day course of amoxicillin in 2009 (8 years ago) but it had never been taken off of her list. With electronic prescribing, a physician can set a duration of therapy (or set a stop date) and after that time, the medication falls off of the medication list. However, even if only 14 pills are prescribed with no refills, if the physician does not set the duration or stop date, then that medication stays on the list in perpetuity. I prescribe a lot of short courses of prednisone and antibiotics and so I have my own prescriptions for these commonly prescribed short-term medications in my “preference list” in our electronic medical record and these include a fixed number of days duration. But many physicians don’t have a preference setting for every antibiotic or other short-term medication that they prescribe and so if they don’t manually enter the stop date every time they write a prescription, that medication will continue to appear to be a long-term maintenance medication forever.
  2. Restricted hospital formularies. Hospital pharmacies cannot stock every single medication that is on the market. First, it is too expensive to maintain that wide of an inventory. Second, each hospital negotiates with various pharmaceutical companies or medication wholesalers for the least expensive of therapeutically equivalent medications in order to keep their costs down. As a consequence, when, for example,  a patient with asthma taking the inhaler Advair gets admitted to a hospital that does not have Advair on the formulary but does have the similar inhaler, Symbicort, then the admitting hospitalist will prescribe Symbicort while the patient is in the hospital. When that patient gets discharged, it is very easy for Symbicort to show up on the discharge medication list but since the patient does not know that Advair and Symbicort are equivalent drugs, that patient will start taking both inhalers. When that patient then sees a primary care physician, the medication list will include Symbicort instead of Advair even though the patient is now taking both drugs.
  3. “Don’t mess with my medication list”. Frequently, the responsibility for maintaining an accurate medication list falls to the primary care physician and in large, multi-group practices, specialists are often told not to take anything off of the patient’s medication list unless checking with the primary care physician first in order to insure that the list is, in fact, correct. The problem is that nobody has time to check with a patient’s primary care physician every time a patient says that they are not taking a medication that appears on their list so the path of least resistance is for specialist to never delete a medication from the list, only add new medications that they prescribe.
  4. Leaving medication reconciliation only up to the doctor. Medicare sets the rules for what nurses or medical students can document in the medical record and what the physician has to document. The “past medical history” is a chart component that nurses and medical students are permitted to document. The past medical history is supposed to include the patient’s medication list. Consequently, in many practices, the first time a patient is seen in that practice, the nurse will record the past medical history, including the patient’s allergies, previous surgeries, and current medications. Because it takes a lot of time to enter a long list of medications (including dose, frequency of administration, etc.), it makes sense to have a nurse or medical assistant do all of that documentation, thus freeing the physician’s time up to see more patients. But in many parts of the country, medication reconciliation is considered to be equivalent to prescribing a medication and so physicians are the only ones who can do medication reconciliation which includes taking medications off of the list when a patient reports that he/she is no longer taking them. Thus, the nurses can add to the list but only the physicians can delete from the list. This creates duplicate work and confusing responsibilities and as a consequence, errors occur. In the hospital, deleting a medication from the medication list directly affects the patient’s treatment and should only be done by a physician; however, in the outpatient setting, deleting a medication from the medication list is more justifiably done by a nurse if the patient says that they do not take that medication any longer. It is very important to distinguish the role and responsibility of the nurse in adding/deleting medications from the medication list in the inpatient setting versus the outpatient setting. Your practice has to decide whether maintaining an accurate medication list in the outpatient electronic medical record is part of recording the past medical history or a part of the medication prescription process – if you consider it part of the past medical history, then empower the nurses to do it.
  5. Medication lists cluttered with non-medication orders. In most electronic medical records, a lot of stuff that gets ordered ends up in the medication list because the EMR doesn’t know what else to do with it. Thus, disability parking placards, the influenza vaccine that the patient received 3 years ago, home oxygen, and wheelchairs will show up in the medication list. This ends up making the list excessively long and more confusing for anyone who is looking at it.
  6. What is the truth, really? Is the “one true source” a list of what the patient says that he or she is actually taking or what the doctor thinks that they are supposed to be taking? If you ask 100 doctors, 50 of them will say it is what the patient is actually taking and the other 50 will say it is what was actually prescribed. So, if a patient was prescribed a medication for gout, but never filled the prescription because it was too expensive, should that medication be on the patient’s list? One the one hand, it is the medication prescribed to treat the gout so you want to have that as part of your on-going medical record. But on the other hand, if the patient isn’t taking it, then should it keep appearing in the medical record? This is controversial and there is no perfect answer.
  7. Samples. If you give a patient a sample of a medication in the office, then you want to have documentation of them getting that medication, for example, a small tube of a steroid cream that a dermatologist gives a patient for their poison ivy. But once again, if there is not a stop date when you enter the sample in the medication list, then it stays on the list until someone else takes it off of the list at a later date.
  8. Bad data from other institutions. Many EMRs have the ability to interrogate other hospital systems that the patient has visited to pull in medications from that hospital system’s medical record. Even if the physicians in your hospital system are tediously compulsive about keeping an accurate medication list, unless the other hospital system’s doctors are equally compulsive, you can pull in errors into the patient’s medication list.
  9. There just isn’t enough time. When a patient gets admitted to the hospital, usually there is a nurse, a pharmacist, and a physician, all reviewing the patient’s medications. The patient is usually in the hospital for a few days so there is ample time for a thorough review and reconciliation with checks and double checks. But in the outpatient physician office, the responsibility for medication documentation often all falls solely the physician. Even if the office nursing staff participate, the time that the patient is in the office is so short that it is hard to get everything done. A typical physician’s return office visits are scheduled every 15 minutes. That means that in those 15 minutes, the physician has to review the patient’s history and any new test results, take an interval history from the patient, do a physical exam, discuss their findings and recommendations with the patients, order any new tests or medications, document a note, create a letter to the referring physician, enter their billing charges, and do the medication reconciliation. Often, there simply just isn’t enough time to do all of that and frequently the first corner to get cut is to skip the medication reconciliation. Some people would say that the answer is to schedule patients every 20 minutes, rather than every 15 minutes. However, over the course of a full day, that would equate to 25% fewer patients being seen that day and the reduction in revenue associated with 25% fewer patients would put most practices out of business.
  10. Poorly designed EMR workflows. A physician will naturally go to three windows in the electronic medical record: the progress note window, the test results window, and the orders window. Anything else and they will need a prompt. If the nurses in the office are permitted to mark medications for deletion but are not actually permitted to delete those medications from the medication list, then there has to be a prompt for the physician to go to that medication list window to approve those deletions. Otherwise, they will close that encounter without ever deleting those medications. Either the nurses should be empowered to delete medications that the patient says they are no longer taking or there needs to be a hard-stop to go to the medication list window before the physician can close the encounter.

The good news is that there are some concrete things you can do to reduce the inaccuracy of the medication list. Here are a few:


  1. Be sure that all short-term medications and samples have a  stop date in the initial prescription.

  2. Develop an agreed-upon consensus among all of the physicians in the organization about whether they define the medication list as the list of medications prescribed for the patient or what the patient says that they are actually taking.

  3. Develop an institutional policy that all physicians are allowed to delete medications from the list – the primary care physician or any specialist.

  4. Allow office staff to work at the top of their license with respect to adding or deleting medications from the outpatient’s list.

  5. Develop a simple practice to ensure that therapeutic substitutions made for inpatient formulary reasons at the time of admission to the hospital are substituted back to the patient’s normal outpatient equivalent drug.

  6. Create workflows in the office that are consistent so that everyone knows their role in maintenance of the medication list and performs that role on every patient.

  7. Design the electronic medical record so that the physician’s tasks for outpatient medication reconciliation becomes a natural part of the workflow or so that medication reconciliation is required before the encounter can be closed.

  8. Involve the patient by printing a copy of the medication list when the patient arrives to the clinic and having him/her review the list for additions/deletions.

November 6, 2017

Categories
Electronic Medical Records

Why You Don’t Really Hate Your Electronic Medical Record

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:

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. Documentation of whether the patient is a smoker in order to meet Medicare value-based-purchasing requirements – 1 mouse click.
  7. 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.
  8. 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.
  9. 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.
  10. 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.
  11. 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.
  12. 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

Categories
Electronic Medical Records

Flagellation With The Electronic Medical Record

Humans always have a way of making their lives harder than they really need to be. The electronic medical record gives us a great tool to do this and creates an opportunity for endless self-flagellation. Our hospital (Ohio State University) uses Epic, a pretty good electronic medical record. I also practice at Select Specialty Hospital that uses Epic. My wife practices in another hospital in town that also uses Epic but how the same electronic medical record program is used is completely different at each of the three hospitals. It illustrates how the same EMR can make your life easier in one place and be torturous in another place.

Past Medical History

At OSU, we load the past medical history, surgical history, smoking history, and family history into a location in the EMR where it can be pulled into every new progress note. That way, you don’t have to type all of the information into your note each time. At my wife’s hospital, the culture is that in the outpatient setting, this information should be obtained independently and typed in by every different physician who uses the EMR. So, the physicians spend far more time for each new H&P and each new consult that they create. Waste of time.

Medication Reconciliation

This is a problem for every physician and every hospital in the country. It means confirming what medications the patient is and is not currently taking. We do it whenever a patient is admitted to the hospital and discharged from the hospital. And we do it at every outpatient visit. It takes a lot of time and when physicians get busy, they usually don’t bother to update the master list of current medications in the chart. At my wife’s hospital, they are also required to do medication reconciliation for phone calls, even for simple refills. That means going through the entire medication list and confirming each medication, dose, and instructions. The problem: it discourages the use of the EMR for phone calls and refills since it is easier to just call them in to the pharmacy rather than send them in through the EMR and have to do all of the medication reconciliation.

Traditionally, the patient’s medications are considered part of the “past medical history”. For Medicare and insurance purposes, non-physician staff (RNs, LPNs, MAs, etc.) can enter information into the past medical history to update the patient’s record. This is enormously helpful for new patients when all of the patient’s previous medical illnesses, allergies, smoking history, surgeries, medications, and family history have to be entered into the EMR. An efficient medical practice allows all of the office staff to practice at the top of their license so that the physician does not need to spend valuable time typing in all of this information. At most hospitals, entering those historical medications is considered part of the past medical history so the MAs and LPNs can enter all of that information, leaving the doctor more time to spend with the patient. However, many hospitals consider deleting any medication that the patient reports that they are no longer taking as a medical order, meaning that it has to be done by a physician and not the RN, LPN, or MA. As a consequence, physicians have to manually delete any medications. Unfortunately, the “delete medication” window is not window that the physicians necessarily go to so most of the time, physicians fail to delete medications. Consequently, there is the potential to have medication lists that include 2 or 3 different doses of a hypertensive medication listed and have antibiotics stay on their medication list even though they only took them for seven days in 2009. Excessive regulation = bad data.

Billing

At OSU, we do our billing through the EMR so that when a note for a patient encounter is completed, you go to a separate window and enter all of the billing data. This is easy for outpatients because the program is set up so that you cannot close that particular encounter on the computer until you enter the billing data; so the encounter continues to appear on your EMR screen until you enter the data and close the encounter. For inpatients, there used to be no way of ensuring that the billing information was completed for daily notes; if you didn’t remember to open the “charge capture” window after you did a progress note, then no bill was created. The result is that 5-7% of all inpatient physician encounters can go unbilled. So, we worked with Epic to create a billing information window that would automatically pop up whenever a physician completed an inpatient progress note and this has significantly reduced unbilled encounters. In Select, there are billing screens in Epic but they cannot be tied into our physician billing department so the physicians have to complete paper billing sheets for each encounter. The problem: it can take an additional 20 minutes to fill out all of the billing sheets at the end of the day and many encounters go unbilled. Furthermore, many physicians do not realize that the billing screens don’t connect to our billing department and continue to enter the billing information in the Select Epic, wrongly thinking that the billing information is going to the billing department. Dollars lost.

Automatic Importation of Diagnosis Codes

When we open the charge window in Epic to enter our billing codes (CPT codes) for inpatient encounters, we also have to enter the specific diagnoses that we were managing with that encounter. At Ohio State, the Epic program remembers what diagnosis codes we entered the previous day and automatically imports them into the charge capture window, thus saving us from having to re-type all of the diagnoses each day. This is particularly helpful now that the United States is using the ICD-10 diagnosis codes that are very, very specific. So, for example, you can’t just enter a diagnosis of “ankle fracture” – you have to enter “ankle fracture, left, closed fracture, acute, subsequent encounter”. Consequently, it can take a long time to find the diagnosis that actually fits the patient. And since most of the time, the physician is seeing the patient for the same diagnoses every day of their hospital stay, automatically importing those diagnoses can save a lot of time that the physician could better spend actually taking care of the patient. On the other hand, at my wife’s hospital, the diagnosis codes are not automatically imported and so the ICD-10 codes have to be re-entered by the physician for each individual charge every day of the patient’s hospital stay. Total amount of time wasted: 5-10 minutes a day.

SmartLists

SmartLists are a selection of phrases that you can insert into a progress note that appear in a drop-down list allowing you to choose one or more of those phrases to insert into a progress note. For example, a SmartList for respiratory symptoms could include: “chest pain, shortness of breath, cough, hemoptysis” allowing you to pick one when you come to that drop-down menu. Epic comes with some built-in SmartLists but they are pretty generic and do not always fit the needs of the individual physician. So, at Ohio State, we have the capability of creating our own SmartLists with whatever words or phrases we want to include in them. However, Select does not grant physicians the ability to create their own SmartPhrases, thus forcing us to use phrases and words that may not exactly fit our needs. The result is that you either have progress notes that don’t really make much sense or the physician has to manually type in all of the words that he/she really wanted to use.

Required Allergy and Medication Review

At Ohio State, when a patient is admitted to the hospital, all of the medications and allergies have to be entered, but the order that they are entered doesn’t matter. At my wife’s hospital, the physician has to click a button attesting that he/she reviewed the allergies before the computer will finalize medication orders. But here is the thing… there is no prompt to review the allergies. So, if the physician fails to review the allergies, they can go ahead and enter all of the admission medication orders but after they are all entered, the orders cannot be signed until the physician goes back and clicks a button stating that they reviewed the allergies. The problem is that all of the medications that the physician just ordered can’t be saved so the physician has to go back and click the “review allergies” button and then re-enter all of the medications that were just deleted when they left the order entry screen.

You can measure how well your physicians are adopting to the electronic medical record by the number of 4-letter words uttered per hour while using the EMR. I call this the PPH (profanity per hour) index. If the index exceeds 20, then you have electronic medical record optimization opportunities.

June 22, 2017

Categories
Electronic Medical Records

How To Use Your EMR To Maximally Offend Your Referring Physician

Many physicians complain that they make too much money. One of the main sources of all of this unwanted money is from consults by referring physicians. In order to reduce one’s income, one very effective solution is to offend your referring physicians so that they send their patients to other doctors, thus causing them to make too much money. The good news is that electronic medical records make it easier than ever before to offend referring doctors. I’m going to show you how any specialist can use the EMR to achieve that ultimate goal of a lower income.

Confuse them.

In the old days, it was harder to be confusing. We used to dictate our referral letters and it was just way too easy to dictate phrases like “Helicobacter pylori”. This led to referring physicians understanding exactly what you were talking about. With the electronic medical record, it is now much easier to just type “HP”. The result of this is that the referring physician reading your letter now has to figure out, “Does he mean Helicobactor pylori? Or hypersensitivity pneumonitis? Or Hewlett-Packard? Or hypertropic prostate?” Abbreviations are a great way to confuse the readers of referral letters, especially those abbreviations that you make up. So, if the patient has pedal edema, put in your note “The patient had AS” – you’ll mean they had ankle swelling but the referring physician will think you meant aortic stenosis and order a cardiac catheterization! Try to put 1-2 abbreviations in each sentence for optimal effect.

Exhaust them.

When we dictated letters, this was really hard to do because dictating an interminably long letter took a lot of your time. With the EMR, we can now insert 10 pages of irrelevant results into a referral letter with a single mouse-click! There is nothing like making the reader of your letters wade through the last 30 potassium levels dating back to 2009 to tire them out. Many EMRs allow you to import all of the meaningless lab and test results into tabular format that is next to impossible to comprehend – a sure way to get the pesky referring physician to stop referring you more patients.

Disorient them.

A great trick I learned from one of our physicians is to vary where you put your impression & plan in your referral letters. Let’s face it, the referring physician could not care less about your review of systems, physical examination, etc. All they really want to know is what you think is going on and what either you are going to do about it or what you want them to do about it. So, the referring physician will automatically skip all of the irrelevant material and go straight to your impression and plan. By sometimes putting the impression & plan at the beginning of your note and sometimes putting it at the end of the note, you can keep them guessing about where to look. If you really want to disorient them, try sometimes putting your impression and plan in the middle of your referral letter! As an analogy, just think of how confused you’d be if the National Hockey League scores were sometimes in the sports section of the newspaper, sometimes in the arts & entertainment section, and sometimes in the middle of the classified ad section. The only danger is that if your referring physician likes playing “Where’s Waldo”, then he or she might actually enjoy the challenge of finding your impression & plan.

Baffle them.

Try writing your progress notes and referral letters in the same language that your teenager uses to text. Use letters like “u” instead of typing “you” and “r” instead of “are”. You can even abbreviate entire phrases like “IMO” for “in my opinion” and “HTH” for “hope this helps”. Whenever possible, drop verbs out of your sentences. Don’t capitalize anything. And remember, punctuation marks are for sissies.

Dodge them.

If you don’t like the question that the referring physician asked you, do what politicians do in a political debate – answer a different question! So, if you get consulted because of a patient’s chest pain and you are completely clueless about what is causing it, then find something else that you can work up, like their plantar fasciitis. There is nothing like “Dear Dr. Jones, Thank you for referring your patient to me for evaluation of crushing substernal chest pain. On exam, I find heel tenderness. My impression is that he has plantar fasciitis and so I will order an MRI of his ankle.” Although it is possible that the referring physician will think you are a genius for figuring out that plantar fasciitis causes referred pain that can mimic angina, it is more likely that they just won’t understand your letter. Another great way to get them to stop sending you patients.

Insult them.

When a referring physician sends you a patient, try to write your note in such a way to be as critical of their initial work-up as possible. If you get a consult for anemia, try inserting phrases such as: “Unfortunately, the patient’s physicians have not ordered screening colonoscopy as recommended by the American Cancer Society.” Or: “This is a textbook classic case of beta thallasemia minor that any 2nd year medical student should recognize.” If these are too subtle, try something more direct like: “The decision to order an iron level without doing a ferritin level was a really stupid idea.” I actually got a letter with a phrase like that in a consultant’s letter to me and so I never sent a consult to that physician again – if it worked for him, it can also work for you!

Belittle them.

A very effective way to alienate the referring physician is to depersonalize them by using phrases like “PCP” and “OSH”. So, if Dr. Smith, who practices at Mercy Mother of Suffering Sorrows Hospital refers a patient to you for consultation, don’t use Dr. Smith’s name in the letter, instead just put PCP for primary care physician. This will depersonalize the referring doctor and emphasis the fact that you consider him or her to be irrelevant and beneath you. There is nothing like starting your letter by saying “Dear Dr. Smith, Thank you for referring the patient to me. She has shortness of breath and her PCP found a new heart murmur.”. In addition to depersonalizing the referring physician, you can also depersonalize that physician’s hospital. Although Dr. Smith may consider Mercy Mother of Suffering Sorrows Hospital as the center of his medical practice universe, you can remind him that his hospital is just a generic small hospital and THE Ohio State University Medical Center is the true center of the medical universe. Using OSH for outside hospital is a very useful strategy. Try writing something like: “The patient had a cardiac echo at an OSH.” Just think of how irritated you would be if you asked for a consultation and the consultant sent you a letter referring to you as PCP and your hospital as the OSH.

By using some of these simple strategies, you too can reduce your income by cutting off the flow of consults from referring physicians. And your electronic medical record makes it easier than ever before to do it.

May 6, 2017

Categories
Electronic Medical Records

Death By 1,000 Mouse Clicks: Electronic Medical Records And Physician Burn Out

Physicians are being sucked into the vortex of their electronic medical records.

I’m on our hospital’s electronic medical record physician advisory committee and so I have access to data about how physicians use the EMR that is not available to the average physician. I was astounded by the amount of time I spend in the EMR and my data is not unique.

I’ve been using our EMR for 9 years and I’m pretty good with it – I close my encounters promptly and at the end of the day, I’ve managed all of my messages, phone calls, and test results. I see patients three half-days a week in the clinic (total 12 hours) and cover our inpatient pulmonary/critical care service 1 weekend a month. Nevertheless, I spend a huge percentage of my time in our EMR.

My average encounter length is 7,369 characters – although most of those characters are automatically imported from templates and the after visit summary, it still results in a lot of typing. For progress notes alone (fewer characters than the entire encounter), as a percentage, 20% of the content of my notes is copy/paste, 15% is manually typed in, and 65% is imported via templates/SmartTools.

I spend 32% of my time generating notes & letters, 24% doing clinical review, 16% managing my inbasket, 11% entering orders, 9% in the visit navigator, 4% in the schedule & patient list, and 4% doing other EMR windows. Granted, the EMR is open a lot when I am doing other activities (in fact, it is open while I am writing this post) so these percentages can be a bit misleading. However, our EMR automatically logs us out after 15 minutes of no use.

I use the EMR a lot of the day. Currently, we are not able to track the total hours per week we are in the EMR (but we are trying to get that data and if so, it will result in a new blog post!), but we can see our EMR activity as a percentage of use and my results are pretty alarming. The graph below shows my own use activity for a 3-week period in January 2017 and this is pretty representative of my use activity in other months.

My EMR use starts to ramp up about 7:00 AM and then tapers off around 7:00 PM with a second peak of inbasket management after dinner around 9:00 PM. To examine use in a different way, we can look at the percentage of time I was in the EMR while seeing patients in the office (scheduled time) versus times when I was supposed to be doing other things.

If you analyze this data, what you see is that I spend about 2/3 of my total daily EMR time when I am seeing patients and 1/3 of my total daily EMR time when I am not seeing patients. Another way of looking at this is that I spend 2 extra hours doing EMR work for every 4 hours spent in the clinic. And compared to my peers, I’m very efficient. For me, I’m pretty much done with the EMR by 10:00 PM but many of my peers are still in the EMR at 1:00 or 2:00 AM. I’m particularly fortunate because I work with a great group of nurses in the office who really streamline my EMR use.

The literature on physician use of EMRs is surprisingly sparse. A 2013 study in The American Journal of Emergency Medicine showed that during a 10-hour shift, the average ER physician spends 44%of their time doing data entry, 28% of time in direct patient care, 12% of time reviewing test results and records, 13% of time in discussion with colleagues, and 3% of time doing other things. The average ER physician had 4,000 mouse clicks per shift.

An often-referenced 2016 study in the Annals of Internal Medicine looked at 57 physicians during ambulatory care (family medicine, internal medicine, cardiology, and orthopedics) and found that they spent 49% of their time in EMR & desk work, 33% of time in direct patient care, 1% doing administrative tasks, and 19% doing other activities (including personal breaks, travel time, etc.).

A 2013 study by the RAND corporation commissioned by the American Medical Association identified 9 reasons that physicians disliked their EMR:

  1. Time-consuming data entry
  2. User interfaces that did not match clinical workflow
  3. Interference with face-to-face care
  4. Insufficient health information exchange
  5. Information overload
  6. Mismatch between meaningful-use criteria and clinical practice
  7. High cost of acquiring and maintaining the EMR
  8. Requirement of physicians to perform lower skilled work
  9. Template-based notes degraded the quality of clinical documentation

A 2015 study in the Mayo Clinic Proceedings found that of the 6,375 physicians surveyed, those that used EMRs had a higher burnout rate (57%) than those that did not use EMRs (44%). Physicians who used EMRs also reported lower satisfaction with the amount of time spent on clerical tasks.

In a previous post, I satirically outlined the strategy hospitals can use to ensure that their physicians get burned out. Electronic medical records are clearly one of the factors contributing to burnout and it is incumbent on us to devise ways to improve physicians’ interface with the EMR to make the EMR work for the physician rather than the physician work for the EMR.

April 26, 2017

Categories
Electronic Medical Records

Stepping Up Your Documentation Game

Once upon a time, long, long ago, physician progress notes were a way of recording the patient’s condition and your treatments in the patient’s chart in order to communicate and ensure optimal care to the patient. You can lament that those days are gone but that will do you about as much good as lamenting that Homo sapiens are no longer Austrolopithecus. The progress note has evolved into a component of the hospital bill. Often times, what we write in the chart is not what we need to take care of the patient but rather what the billing department needs in order for the hospital to get paid.

In a previous post, I described the documentation game, where we use key words in the chart as adjectives to describe the patient’s severity of illness in order to lower the hospital’s mortality index. In this post, I’m going to show you how to use key words in the progress note to increase hospital reimbursement for inpatient care.

When a patient is admitted with an illness, the hospital gets paid by the insurance company (or Medicare/Medicaid) based on the patient’s primary diagnosis and not on how long the patient was in the hospital or how many charges the hospital accrued during the hospital stay. The hospital then gets paid more depending on the number of various comorbid conditions that the patient had at the time of admission – in other words, the sicker the patient, the more the hospital gets paid for any given primary diagnosis. So, in order to get paid as much as possible, the hospital has to be sure that all of those comorbidities are captured in the medical record. The hospital that documents comorbidities the best, wins the game. But there are a few rules to the documentation game:

  1. The comorbid conditions have to be documented by a physician. Conditions noted by a nurse, dietician, respiratory therapist, or social worker don’t count.
  2. The comorbid conditions have to be documented as being “present on admission”. If these conditions are in the emergency room physician’s note or in the admission history and physical, then they are considered as present on admission. However, if a comorbid diagnosis is identified and/or documented later in the patient’s hospital stay, then the physician has to state in a progress note that the condition “was present on admission”, otherwise, it doesn’t count.
  3. Diagnoses that only appear in a test result (lab result, pathology report, x-ray report, etc.) do not count. The diagnoses have to appear in an H&P, progress note, op note, procedure note, or discharge summary.
  4. Signs and symptoms don’t count.
  5. Lab values don’t count – only the physician’s interpretation of lab values count. So, you can’t just document that “the patient had a potassium of 2.5 so I will order potassium replacement”, instead you have to document that “the patient had hypokalemia so I will order potassium replacement”.
  6. The more specific you make the diagnosis, the more points you get and therefore the more you get paid.
  7. Using the words “likely, “suspected”, or “probable” in front of a diagnosis counts in the documentation game. You don’t have to know for sure that the patient has that specific condition.
  8. Certain words diagnoses that mean everything to you from a clinical management standpoint may mean nothing from a coding standpoint. So (as crazy as it sounds), urosepsis doesn’t count but sepsis does count.

In order to be sure that all of those comorbid conditions that were present on admission are captured in physician documentation, hospitals employ clinical documentation improvement specialists who comb through the charts to hunt for evidence that a patient had a particular comorbid condition that wasn’t documented by a physician. When they find one, they send a query to the attending physician or resident asking if the physician agrees that the condition was present and if so, asking the physician to add documentation to that effect in a progress note. Each of these diagnoses translates to a “risk adjustment factor” (RAF) number and when you add up all of the RAFs, the total score determines how much additional the hospital gets paid for any given admitting diagnosis.

Here are some concrete examples of how you can improve your hospital’s score in the documentation game:

  • A patient is admitted with a right lower lobe infiltrate and has type II diabetes with an elevated glucose. The patient also has chronic pain and has failure to thrive. Those two sentences get you 0 points. Now lets see what happens if you use some diagnosis words rather than signs and symptom words in your note: A patient is admitted with a suspected aspiration pneumonia (0.292 points) and has poorly controlled type II diabetes (0.496 points). The patient also has opioid dependence secondary to chronic pain (0.055 points) and has moderate protein calorie malnutrition (0.409 points). Now, those two sentences get you an RAF of 1.242 points.
  • A patient is admitted with suspected gram negative pneumonia and hypoxemic respiratory distress  with an increased lactate will get you 0.7028 RAF points and the hospital will be paid for a 2.8 day length of stay. However, if the patient is admitted with suspected gram negative pneumonia and chronic respiratory failure with an increased lactate, you now get 0.9469 RAF points and the hospital gets paid for a 3.6 day length of stay. Even better, if the patient is admitted with suspected gram negative pneumonia and acute respiratory failure with hypoxemia and lactic acidosis, you now get 1.3860 RAF points and the hospital gets paid for a 4.6 day length of stay.
  • A patient similar to the last one but has sepsis from a urinary source:
    • “Urosepsis with SIRS, acute hypoxic respiratory distress, and an increased lactate” gets you 0 RAF points and no length of stay days.
    • “Sepsis, acute hypoxic respiratory distress, and an increased lactate” gets you 1.0283 RAF points and 3.8 days length of stay payment.
    • “Sepsis, acute respiratory failure with hypoxemia, and lactic acidosis” gets you 1.7660 RAF points and 4.8 days length of stay payment.

However, Medicare and insurance companies have determined that the documentation game wasn’t challenging enough so they added some more rules to make it harder to get RAF points:

  • For patients admitted with pneumonia, you get more RAF points if you can specify the type rather than just documenting “pneumonia”. So for example, “aspiration pneumonia” or “gram negative pneumonia” gets you more points. Don’t forget, that you are allowed to use the word suspected. So, for example, if you are prescribing vancomycin for a patient with pneumonia on the chance that they might have MRSA, put in your note “suspected MRSA pneumonia” rather than just writing “pneumonia”.
  • “Altered mental status” doesn’t count for any RAF points (it is a finding and not a diagnosis). So, instead, that patient has “acute encephalopathy” in your progress note.
  • “Unresponsive” doesn’t count but “unconscious” does.
  • “Drug-induced delirium” is a psychiatric code and doesn’t get you very many RAF points. It is better to document “toxic encephalopathy”.
  • If someone has a body mass index > 40, you get more points for documenting “morbid obesity secondary to excess calories” than you get for documenting “morbid obesity” alone.
  • For patients with heart failure, you get more points if you add the words “acute” or “chronic” and you also get more points if you add the words “systolic” or “diastolic”.
  • Avoid the word “dysfunction” as it doesn’t count for any points. So, for example, a patient does not have left ventricular dysfunction, they instead have left ventricular failure.
  • “Do not resuscitate” gets you no points but “palliative care” gets you lots of points. So, if you have a discussion with a patient and the patient decided to not undergo resuscitation, don’t document: “I spoke with the patient and he wants to be DNR“. Instead document: “I had a palliative care discussion with the patient and he wants to be DNR“. The terms comfort care, end-of-life care, and hospice care are all considered synonymous with palliative care when it comes to RAF points.
  • To maximize your RAF points, nobody should have “dementia requiring a sitter”. They should always have “dementia with behavioral disturbance”, “dementia with aggressive behavior”, “dementia with violent behavior”, or “dementia with combative behavior”.

The documentation game is by necessity a team sport and the team that wins will have both the strongest physician and the strongest documentation specialist. But it is not enough to be individually good, the physician and the documentation specialist has to work well as a partnership. Better cooperation between the doctor and the documentation specialist = more RAF points = more money for the hospital = better donuts in the physician lounge.

April 13, 2017

 

Categories
Electronic Medical Records

Using 50 Words To Express A 6-Word Thought

My college freshman English professor told me: “You are not writing for yourself, you are writing for your reader. Always put the reader first.” It is a great message… and one that electronic medical records (EMRs) have made us totally forget. That professor would once a week have us critique an article by a particular reporter for the Cincinnati Enquirer – our job was to completely tear it apart from the perspective of the reader. If he could get a hold of a single progress note from our hospital’s electronic medical record, he would have a enough material for an entire semester.

In a previous post, I mentioned that there are fundamentally 3 reasons to have a progress note:

  1. To communicate with other healthcare providers
  2. To provide documentation for medial-legal purposes
  3. To provide documentation for billing purposes

Electronic medical records make it really easy for us to document for billing but as a communication tool to other healthcare providers, they often fall woefully short. Our hospital uses the electronic medical record program, Epic. It is an incredibly powerful program that allows us to import all kinds of information into a progress note: lab test results, vital signs, past medical history, vaccination records, etc. As a physician, you can go wild with documentation – you can generate a 10-page note full of data just for an office visit note for a patient who comes in to get ear wax removed.

I’m on both the sending and the receiving end of electronic medical record progress notes. From other hospitals, I’ll get printed copies of notes mailed to me – pages and pages of data for a single office visit with a doctor who is co-managing the patient with me. From our own hospital, I’ll get notes from a colleague in a different specialty routed to my electronic medical record “Inbasket” and I’ll need to scroll through mounds of regurgitated data just to find the physician’s impression and plan.

But here’s the thing. If I’m treating the a person’s COPD, I don’t really need to know nor care about what their chloride level was in 2011 or the results of their last 6 normal EKGs. If I need that information, I can go to the lab or EKG section of the electronic medical record and I don’t need that information clogging up a progress note sent to me by another specialist seeing the patient for an unrelated problem.

The electronic medical record is a great documentation tool but we make it a poor communication tool.

Fear has taught us that more is better. If we include everything in the patient’s chart in our progress note, then surely we’ll get all of the right elements to withstand a Medicare billing audit. And shouldn’t we include every lab test the patient has had in the past 3 years just in case the person reading the note wants to see them? As a referring physician, I don’t really care about reading a consultant’s 11-point review of systems and re-statement of the patient’s family history since I already know this information and it is just a click away on the EMR if I need it. When it comes to really communicating in an EMR, less is usually more.

Don’t make the reader have to work to read your note.

There is a reason that we speak in sentences and that books are written using sentences. It is the most efficient way that we process the communications that are given to us. Tables and lists can help support the sentences but it takes a lot of time and brain energy to analyze tables and lists and in an EMR, most of them are just unnecessary fluff for the reader. When I get a communication from another doctor, what I really want to know is what their impression of the patient’s disease is and what they plan on doing about it. Sometimes that impression and plan is at the beginning of a long note of otherwise tabular documentation garbage, sometimes it is at the end, and sometimes it is in the middle – causing us to scroll up and down the notes trying to find out the information that we really want to know. The reader shouldn’t look at reading the progress note as a chore. The absolute best communications I get are from one of our surgeons who sends me a 1-paragraph letter saying what he thinks the patient’s problem is and what he is going to do about it. He communicates more in 2 sentences than most routed EMR notes communicate in 6 pages.

An inpatient progress note is often a communication to the outpatient physician.

My return outpatient visits are scheduled every 15 minutes. That means that when I see a patient in the office after a hospitalization, I have 15 minutes to review the record, talk to the patient, do an examination, order tests and medications, and complete my office note. I don’t have 7 or 8 minutes to spare to hunt through the recent inpatient chart to figure out what was going on with the patient and what I need to specifically follow up on. So I go to the last pulmonary consult note in the inpatient chart to see what pulmonary problem the patient was in with and what I need to be focusing on. If the patient needs a follow-up chest x-ray, or pulmonary function tests, or a decision about when to stop a pulmonary medication, I’m expecting that note to have that information. In this sense, the inpatient progress notes are not just a communication to the other physicians and practitioners seeing the patient in the hospital, they are also a communication with the outpatient physicians to insure a smooth transition from inpatient to outpatient care. Often, I’m both the pulmonary consultant in the hospital and the outpatient pulmonologist for a given patient and in this situation, my inpatient notes are notes to me and the nurse practitioner that I work with.

Don’t use a $25 word in a 25¢ sentence.

William F. Buckley was the conservative host of the TV show Firing Line and was famous for using 5 syllable words that he would pull from deep in the bowels of the English dictionary. He sounded extremely learned and intelligent but the average person couldn’t understand half of what he said. He used his extensive vocabulary like a weapon in political debates. That is great for entertainment but terrible for trying to communicate critical medical information to a wide audience of healthcare providers who will be reading your note. So don’t describe a person as macrosmatic, valetudinarian, or pauciloquent in an EMR note just because it showed up this morning on your “word of the day” app – no one else knows what it means any more than you did yesterday.

January 27, 2017

Categories
Electronic Medical Records

The PATH Audit That Almost Was

There are fundamentally 3 reasons to have a progress note:

  1. To communicate with other healthcare providers
  2. To provide documentation for medial-legal purposes
  3. To provide documentation for billing purposes

In the 1980’s, communication with other healthcare providers reigned king. We marked up medical student H&Ps with red ink if they didn’t have perfect grammar and we carefully dictated referral letters and then edited them before sending them out. Nobody cared about billing documentation back then – it just wasn’t important. All of that changed on June 21, 1996, when the Office of the Inspector General announced the PATH audits – “Physicians At Teaching Hospitals”. Although designed to be a way to protect Medicare against billing fraud, the PATH audits turned into the medical billing equivalent of the Spanish Inquisition. Federal Inspectors would do probing chart reviews of physicians at academic medical centers and if they found charts that didn’t have the right documentation elements, they would swoop in and do a massive audit of all of the physicians, often resulting in fines of 10’s of millions of dollars.

It was easy for these investigators – Medicare had established billing rules and required that the each progress note contain sufficient elements to justify different levels of billing. So, for example, a given level of billing for a new patient visit had to have at least 3 symptoms, a past medical/social/family history, 9 different systems documented in a review of systems and at least 11 different body parts examined. If the inspectors (who were not physicians) did not find all of those elements, the physician had to pay back the money from that particular bill and was also susceptible to an additional fine for each progress note that didn’t pass muster.

Although there were examples of clear fraud, for example, a surgeon who billed surgical procedures in Minnesota but had credit card receipt documentation that he was in London, England at the time, most of the cases labeled as “fraud” were really just good doctors trying to take care of patients but not documenting every part of their physical exam or forgetting to list all of the patient’s previous surgeries in their H&Ps. There was also a dark side of the PATH audits because they could also be vindictively.

You see, if a person called the Inspector General’s whistleblower hotline and it resulted in an audit of a physician (or better yet, a large academic medical center group practice), then the whistleblower got to keep up to half of all of the fines that the government collected. You could become a multimillionaire simply by calling in the dogs of the Inspector General.

In the late 1990’s, I was the subject of such a vindictive investigation. We had recently cut the salary of some of the physicians in our group because of low productivity and I was in charge of the clinical/financial management of the group. That year, 3 of our physicians left and one particular physician left the University, harboring a lot of anger and resentment, mainly directed to me since I was perceived as the one who cut his salary. So, he called the Inspector General’s whistleblower hotline alleging that I had fraudulently billed millions of dollars to Medicare. Because of the enormous dollar amount alleged, the OIG descended on our hospital’s medical records department and pulled every single progress note, procedure note, and H&P I had written or co-signed over a 3-month period.

It took them months to comb through thousands of my notes and with each note, they had a scorecard that they would check whether or not I had enough review of systems documented and enough body part examinations documented. It must have cost the OIG a small fortune to send investigators to review all of these notes. We hired an attorney to represent me through this process because of the fear that if I didn’t have the right documentation, it could open the door to a dreaded PATH audit that could essentially wipe-out the physician faculty ranks at Ohio State University. After the completion of the audit, here is what they found:

  1. I had over-billed by one level about 5 times (I had to pay back the difference – total was less than $100)
  2. I had under-billed by one or two levels about 25 times (total was about $2,000 but they don’t give you any money back in this situation)
  3. I had a few notes that I had written when billing ventilator management charges (used by pulmonologists rather than the more documentation-intensive return visit charges). Unfortunately, in addition to my notes, my medical students also had notes in the chart that referred to the ventilator settings and ventilator weaning. Because Medicare classifies ventilator management as a procedure and because any procedure done by a medical student, even with full supervision by the attending physicians, cannot be billed to Medicare, they asked for all of the money back for these notes – total about $200. Although I had done all of the actual ventilator analysis and written all of the orders, since the students also documented the ventilator settings, they said that the “procedure” of ventilator management involved medical students so I couldn’t bill it.
  4. I had come into the hospital one night to see a patient with acute respiratory failure in the ICU – I intubated her, put a central line in her, and did a bronchoscopy. In addition to the procedures, I also billed a critical care charge – for this charge, you have to document that you spent at least 31 minutes providing critical care services independent of any procedures. I had my documentation right there – 11:40 PM to 12:25 AM and I had each procedure note timed with a different time either before or after the critical care times. However, the auditors stated that since the time crossed midnight, 20 minutes of the time had to be accounted to one calendar day and 25 minutes to the next calendar day and since neither of the days’ time was >31 minutes, I couldn’t bill any critical care charges and in fact, was not allowed to bill anything. I had to give back $175.

Before this, I had been a documentation freak so my notes were actually very well-documented and so the amount I had to pay back to Medicare was truly trivial. The OIG spent many times that much in salary, hotels, food, and airfare for the inspectors that they sent to Columbus. My ex-partner got nothing as a “whistle-blower” and our University did not get a resultant PATH audit.

Our electronic medical records now make it simple to ensure that each note has the required number of body parts examined and the correct minimum number of systems documented to be reviewed in the review of systems. The PATH audits have gone away because there just isn’t any money in it for the OIG anymore. However, the legacy of the PATH audits is the topic of my next post – the cluttering of physician progress notes with excess documentation by doctors who do electronic medical record documentation overkill to avoid even a chance of not having enough documentation to support a Medicare bill in the event of an audit.

January 23, 2016