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AAOS Now

Published 7/1/2010
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Cheryl L. Toth

Is your EMR fueling risky record keeping?

Not all timesavers are helpful

Simply implementing an electronic medical record (EMR) system won’t necessarily reduce your risk of an audit. On the contrary, if you don’t use the system’s documentation features properly, EMRs may actually increase your risk of an audit.

Bubble sheets
Bubble sheets—preprinted response sheets similar to those used in academic testing or research surveys—are used in some EMR systems for patients to report their family and medical history. According to documentation guidelines, anyone can provide or collect past family and social history, but the physician must sign off on the form before it’s entered into the record. Unfortunately, in many busy offices, the physician simply scans the bubble sheet before signing it.

“This might save time, but it’s essentially creating an invalid document,” said Mary LeGrand, RN, MA, CPC, CCS-P, a consultant with KarenZupko & Associates.

In one orthopaedic group, a bubble sheet listed possible symptoms such as fractures, joint pain, or spasms, but did not include an option for ‘no complaints.’ Additionally, the directions were unclear so that patients didn’t realize they were supposed to select all that applied.

Ms. LeGrand explained, “Because the bubble sheet had no negative response option, the EMR was automatically generating a note stating ‘negative for joint pain, muscle pain’—even though the patient hadn’t specifically responded to anything on the bubble sheet.”

In this case, the practice should have insisted the EMR vendor add a ‘yes/no’ option for all values under each system or provided a ‘no complaints’ option for each. (See sample PDF)

Collecting family history on bubble forms can also be an issue. “In a busy practice, proper collection of family history is sometimes overlooked,” Ms. LeGrand said. “That’s bad enough when the history is saved on paper, but in the electronic world, it’s even more dangerous. An EMR system that automatically populates information indicates there was some kind of response when, in fact, no information was ever obtained from the patient.”

Don’t be swayed by code calculators
Some vendors will claim that the EMR system will ‘code’ for you and help your practice make more money. Don’t count on it.

For example, one orthopaedic group noticed an increased number of high-level evaluation and management (E/M) codes after their EMR system went live. “They looked at the algorithm on the medical decision-making component and realized it was simply incorrect,” Ms. LeGrand said.

The system’s incorrect logic prompted it to suggest an incorrect, higher level E/M code. When the practice did an internal audit and recognized the inaccuracy, the billing team began to override the suggested code and bill the correct code.

At issue is the logic behind the code calculator itself. “Suggesting code levels that don’t match the documentation can put a practice at risk,” Ms. LeGrand warned.

Practices should be concerned about this issue, according to consultant Kim Pollock, RN, MBA, CPC. “Over the past 3 years, the percentage of 99214 and 99215 codes processed by Medicare has increased in almost all specialties.” According to an article in Part B News, the “proliferation” of EMR systems “allows easier documentation,” thereby justifying higher E/M levels. It’s likely Medicare may target these code levels for an audit sooner rather than later.

When shopping for an EMR system, ask the vendor to create a chart note using documentation from visits with patients who have conditions commonly seen in your practice. This will enable you to ensure that your “pick list” selections result in accurate documentation.

Test documentation workflow
“I advise clients not to go live until all the customization is done and tested, and everyone understands how the EMR will affect patient flow and documentation workflow,” Ms. LeGrand said. “Physicians really need to access the system before it goes live and understand how it will change their workflow, and the flow of information in the practice. Otherwise, significant backlogs may occur.”

For example, backlogs can occur if the person creating the task list is not computer savvy or if the practice has insufficient staff to enter required health history information to open a visit note before a patient encounter.

Each practice will have to identify workflow changes and make the necessary adjustments. Because the vendor or information technology (IT) department rarely understands the nuances of orthopaedics, they won’t be able to help modify daily close processes or documentation/sign-off processes. Doctors, staff, and managers must pay attention to how the EMR will change the workflow and adjust processes.

In a “worst-case” scenario, the workflow in an EMR system could be so labor-intensive that documentation doesn’t get done at all.

The bottom line is this: Customizing an EMR and modifying processes and information workflow will take much longer than most practices expect. But, taking these important steps will reduce risk exposure and improve EMR success.

“Take the time to understand your documentation baseline, know your processes, and understand all the information flow points that are going to change,” advised Ms. LeGrand. “Otherwise, you’ll be sorry in the long run.”

Cheryl Toth is a consultant with KarenZupko & Associates, Inc). She can be reached at (312) 642-5616 or ctoth@karenzupko.com

5 tips for minimizing EMR documentation risk

  • Have a third party review your documentation before you go live.
    Getting an outside opinion will save money and reduce risk. Ideally, the audit should occur during the planning and implementation process, and it should include a baseline reading of E/M code usage so that you can compare it to coding and documentation after the system goes live.
  • Carve out plenty of time for customizing visit templates.
    Practices must review and customize the stock templates provided by the vendor. Otherwise, the system will create multi-page, rote notes that don’t necessarily document what was actually done. Once you customize the vendor templates for common conditions, create additional templates for every condition you treat.
  • Verify the coding calculator algorithms.
    Orthopaedists rarely can support the use of code 99215. If your EMR system’s coding algorithm is consistently upgrading E/M codes, you may need to adjust the algorithm.
  • Review notes ‘pulled forward’ from previous visits.
    Messy documentation can signal red flags to auditors, attorneys, and other chart reviewers. Make sure to review every note and every visit—just as you would in a paper chart world.
  • Ignore vendor promises of “boost your coding revenue!” and “download and implement our system in 24 hours!”
    Despite what vendors may tell you, you will not be up and running in 2 weeks. Planning and implementation are hard work and customizing your visit templates takes many hours. Even if you do everything right, full implementation will take 6 to 12 months after you go live; complete adoption of the EMR can take 18 to 24 months.