By Cheryl L. Toth

Customize templates to ensure accurate documentation

If you’re evaluating electronic medical record (EMR) systems, or have recently implemented one, don’t be fooled into thinking that the risk of an audit disappears after going digital. In fact, EMRs may actually increase your risk of an audit—unless you use the system’s documentation features properly.

Recent audits of orthopaedic practices reveal inaccurate descriptions of patients’ reports or physicians’ actions. Rote notes go on for pages and pages and, in some cases, documentation does not support the level of evaluation and management (E&M) services coded and billed, leading to unintended upcoding that could trigger an audit.

This article, the first of two examining the risks involved with implementing a new EMR system, will focus on the need for customizing the templates included with the system. Next month’s article will examine focusing on “timesaving” features that may not be all they promise.

Template customization is key
“An overarching issue here is lack of customization to the patient visit template,” explained Mary LeGrand, RN, MA, CPC, CCS-P, a consultant with KarenZupko & Associates. “In most cases, practices get little or no help from the EMR vendor in customizing templates.”

As a result, surgeons often make the mistake of skipping or delegating this important step. In one orthopaedic practice, a physician assistant (PA) was assigned the responsibility of customizing the template; but the PA had no coding experience or understanding. Similarly, if a practice administrator does the visit template customization, surgeons may not find the templates useful.

“The exam template used by a spine surgeon bears little resemblance to one that can be used by a foot and ankle surgeon, which in turn is different from one a sports medicine specialist requires,” she explained. “The templates are the most critical step toward making sure the documentation is right. If you bypass template customization, you put your practice at risk.”

Customize common conditions first
As the orthopaedic surgeon, you must be involved in any template customization. Assuming that your practice has been coding diagnoses accurately, ask your practice manager to generate an ICD-9 frequency report. You can then go through this list and customize templates for the conditions you treat most frequently. You can then upload these templates into your “favorites” or “quick” list. Most EMRs have this functionality.

For example, a sports medicine specialist might start with rotator cuff tears, ruptured anterior cruciate ligaments, and meniscal tears. Foot and ankle specialists may choose to customize Achilles tendon ruptures, gait abnormalities, hammer toes, and fracture codes. Reconstructive joint surgeons should create templates for all types and sites of osteoarthritis.

To realize the benefits of customization, practices must be diligent about implementing and using the customized templates. The orthopaedic department of an academic medical center that didn’t initially customize templates for various specialties experienced a great deal of resistance from physicians when it attempted to implement an EMR system. Why? Because it took a long time to hunt for and find the information in the system; no one was using templates or favorites.

“The EMR was primarily targeted to primary care medicine,” Ms. LeGrand explained. “When the time came to implement the system in orthopaedics, the surgeons received no guidance or training about how to create templates or favorites lists.” Of course, templates can be created retrospectively, but this takes even more time. It’s easier and less frustrating if templates are created early—before rolling out the system.

Orthopaedic practices that offer physical therapy (PT) should involve the therapists in template customization. Well-designed templates can provide prompts for the initial PT evaluation. Format the template to match the visit components recommended by the American Physical Therapists Association.

Physical therapy templates should include all the paper-based exercise worksheets used to track the total time of each exercise. The EMR template should allow the therapist to enter not only the time requirements for billing purposes, but also the type of exercises completed during that time increment.

Avoid creating “cloned” notes
Vendors often boast about the automated feature that “pulls” the History of Present Illness (HPI) forward from the previous visit. In theory, this allows physicians to simply review and update the visit—saving them from lengthy dictation or note taking.

But what happens if the notes from the previous visit do not get reviewed? According to E&M documentation guidelines, each record must be allowed to stand on its own. “Letting the system pull the previous history into an autogenerated form without reviewing it is risky,” Ms. LeGrand warned. “Many orthopaedic surgeons get busy and forget to review the ‘cloned’ HPI from the previous visit. But paying close attention to what is being pulled forward is critical because the patient’s current problem could be completely different from the previous one.”

A good example, she says, is the three-pack-a-day spine patient who enters into a nonsmoking agreement prior to a laminectomy. “If the patient sticks with it and the orthopaedic surgeon doesn’t review and update the social history while the patient is being managed conservatively in preparation for spinal surgery, the note will ‘pull forward’ as if the patient is still smoking three packs a day, thus creating inconsistencies in the current HPI and the review of systems (ROS). It could also affect the decision to proceed with surgery,” Ms. LeGrand said.

Another common issue associated with the cloning process is that it creates a verbose chart note that’s not reader-friendly and contains rote responses that don’t necessarily call out pertinent positives. As a result, referring physicians often complain about getting “canned” EMR chart notes from consulting specialists. Because the note has so much extraneous material, the referring physician may skip to the bottom and skip something important.

Contrary to what some orthopaedists might think, an EMR note should essentially mirror handwritten notes—except that it is legible. If normal documentation into the paper chart is about a half-page long, the documentation in the EMR system should be about the same length.

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 implementation success.

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