Why Templates Don't Work
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Praxis EMR - Why Templates Don't Work Articles - Medical Economics

EHR documentation challenges remain

Thomas Payne, MD, FACP, attending physician in the General Internal Medicine Center at the University of Washington Medical Center-Roosevelt in Seattle, dictates notes into a recorder between patient appointments, recording notes on one patient before seeing the next.

He then uses speech-recognition software to move those recorded notes into his electronic health record (EHR) system.

Payne said his system ensures he gets to his notes quickly after each visit, and saves him time. "I do leave the clinic sooner than my colleagues do, by 30 minutes or so," he said.

Although Payne acknowledged that his process "might not be the right choice for every primary care provider," he does see an overall need to develop better practices around documentation.

"Documentation is one of the most time-consuming parts of a doctor's day, particularly in primary care. It's an area ripe for improvement," said Payne, who is also medical director for IT services at the University of Washington School of Medicine and board chair for the American Medical Informatics Association (AMIA).

The rapid rise of EHRs has brought with it both changes and challenges in how physicians record and share their patient notes. Leaders in the medical community have found that when it comes to aiding documentation, the systems need to do a better job.

The Report of the AMIA EHR 2020 Task Force on the Status and Future Direction of EHRs cited the need for EHRs to "simplify and speed documentation," through other members of the care team entering the information, automatic data capture by devices or other information systems, and even having patients enter data themselves.

Payne said most EHRs aren't designed to support documentation in a way that works well for physicians and their staff.

For example, he said many doctors record their notes in narrative form, writing down information that while not necessarily related to what brought a patient in for that particular visit is important to document the patient's overall well-being.

However, Payne said most EHRs want doctors to check boxes or use drop-down fields to add details about a patient; EHRs generally can't take the information recorded in narrative form and use it to populate the preset fields. That means doctors recording the same information multiple times, moving from one field to another on their computer screens.

"That's not particularly satisfying nor is it the best use of that physician's time," Payne said.

Opportunities for improvement

The Accreditation Association for Ambulatory Health Care (AAAHC) in its Quality Roadmap 2016 also singled out issues with documentation, saying it's an area that offers opportunities for improvement.

Cheryl Pistone, the AAAHC's clinical director for ambulatory accreditation said the organization found that a physician's EHR frequently didn't have documentation from external providers nor did it always have enough information in particular circumstances. Namely, EHRs did not contain enough documentation on patients' allergic reactions to medicine nor did they contain updated medication information. Additionally, EHRs do not always contain adequate details on small procedures, such as removing a small growth, done by physicians in their offices.

Pistone said EHRs should be configured to require physicians to add details about allergic reactions and then automatically populate that information in the multiple places within the medical record where it is needed.

EHRs should also be configured to enable doctors to easily enter information in narrative form. Then the EHR should use artificial intelligence (AI) and analytics to populate, parse and present data for physicians when and where they need it, Payne said.

Payne pointed out that leading EHR vendors as well as other software makers are developing and beginning to deploy more of these technologies, while technologies that support interoperability, such as the growing use of the Fast Healthcare Interoperability Resources (FHIR) standard, are speeding advancements on that front.

Improvements are long overdue, experts said.

"Documentation is a great example of where a problem exists today and where the pace of technology improvements is not as great as everyone hoped," said Payne.

Praxis EMR - Why Templates Don't Work Articles - Healthcare Informatics

Small Physician Practice Leaders: EHRs Cost us Money

A study of small physician practice decision makers found that electronic health records (EHRs) will reduce the number of patients seen per day, thereby reducing the practice's revenue.

The survey, published recently in the American Health Information Management Association's Perspectives in Health Information Management publication, included 15 U.S. physicians who have been in their practice for at least five years. None of the survey respondents were in practices with more than four physicians, and all of them were considered "decision makers" in their respective practice.

The respondents reached a consensus that EHRs would reduce the number of patients seen per day, thereby reducing their revenue. Although the panelists limited their discussion on the effect of patient outcomes, their most dominant concern was the loss of face-to-face time with the patient. They felt that the use of an EHR would reduce the focus on the patient and potentially cause physicians to miss medical conditions.

According to recent statistics from the Office of the National Coordinator for Health IT, as of 2015, nearly 9 in 10 (87 percent) of office-based physicians had adopted any EHR, over 3 in 4 (78 percent) had adopted a certified EHR and over half (54 percent) adopted a "basic EHR." Since 2008, office-based physician adoption of any EHRs has more than doubled.

Indeed, a decrease in patient volumes (47 percent of respondents) and a decrease in patient face-to-face time (53 percent) were the two most pressing concerns when asked, "How do you believe the implementation of an electronic health record system would affect the management of small physician practices? Consider the entire practice operations, including but not limited to the patients, the physicians, and the financial implications to the practice." At no point in the study did any panelist state that their practice saw an increase in volume.

What's more, one-third of respondents reported that EHRs could force small businesses out of practice due to cost issues. One panelist noted a recent decision to close their practice and move to a hospital system because they felt their small practice was no longer viable. Others mentioned colleagues who had retired or joined another practice or hospital to avoid the complications and cost of the EHR.

That being said, on the optimistic front, the panelists felt that given sufficient software features and transfer protocols, the cost for medical record management could potentially decrease. Examples of features mentioned were automated processes, streamlined record transfers, and optimized patient portals. Panelists shared that providing a better system for remote access as well as the potential to interact with the patient via a portal system had the potential to improve patient care and possibly reduce unneeded visits for questions that could be handled via messaging.

Security issues relating to hacking and data mining evolved in later rounds as panelists were concerned that technology and legislation had not caught up with the potential security concerns. Several indicated that breaches could result in significant loss of privacy at a level previously unseen.

In the end, panelists felt that vendors did not provide realistic outcome scenarios, leading several of the respondents to state that vendors were "simply salespeople" and were not concerned with how the technology would affect physicians. Improvements in patient volumes as a result of specialized training remain a viable research interest. Vendors may reap better sales outcomes if they shift their focus from sales to implementation, the researchers noted.

"The results of this study indicate an avenue for EHR vendors to develop educational avenues to teach physicians how to optimize the EHR as well as to share success stories that demonstrate improved financial impact," the researchers concluded. They added, "Even with a strong government push for the use of the EHR, physician and patient acceptance and participation will be critical to its ongoing success. At present, neither party is fully on board with the new direction of healthcare delivery, although each remains vitally important. Despite the investments in EHRs and the increase in their adoption, patient engagement continues to lag."

Praxis EMR - Why Templates Don't Work Articles - EHR Intelligence

Improving Clinical Data Integrity through EHR Documentation

Quality EHR documentation can support improvements to patient outcomes when done right.

Source: Thinkstock

Findings from a recent EHR usability study conducted by the National Institute of Standards and Technology (NIST) once brought to the fore the problem of clinical documentation in the digital age of healthcare.

The study of EHR use, particularly copy-and-paste functionality, led to three major findings. First, clinicians participating in the study were concerned about EHR data integrity as a result of copying and pasting information. Second, clinicians identified entering the wrong information into the wrong record as a high potential risk. Third, participants reported that over documentation introduced challenges to accessing "accurate, relevant and timely information on a patient" at the point of care.

Despite its intended purpose to improve the ease and efficiency of clinical documentation, NIST concluded that the copy-and-paste functionality "has introduced overwhelming and unintended safety-related issues into the clinical environment."

Concerns about the accuracy and quality of EHR documentation are nothing new. In a 2013 update to 2007 guidance on EHR documentation integrity, a workgroup convened by the American Health Information Management Association (AHIMA) called for safeguards to ensure electronic documentation did not undermine patient care.

"Without safeguards in place, records could reflect an inaccurate picture of the patient's condition, either at admission or as it changes over time," the AHIMA workgroup wrote. "The provider must understand the necessity of reviewing and editing all defaulted data to ensure that only patient-specific data for that visit is recorded, while all other irrelevant data pulled in by the default template is removed."

What's more, the authors of the EHR documentation guidance emphasized the urgency of addressing how the use of automated EHR functions could compromise the integrity of clinical health data.

"Data quality and record integrity issues must be addressed now, before widespread deployment of health information exchange (HIE)," they maintained. "Poor data quality will be amplified with HIE if erroneous, incomplete, redundant, or untrustworthy data and records are allowed to cascade across the healthcare system."

More recently, research has pointed to a potential disconnect between patient-reported and provider-record health data. Researchers at the University of Michigan sought to investigate whether patient-reported eye symptoms were recorded as part of clinical documentation in EHR systems. Comparing eye symptom questionnaire (ESQ) and EHR documentation, Valikodath et al. found a "substantial discrepancy" between the two.

"Discordance in symptom reporting could be because of differences in terminology of symptoms between the patient and clinician or errors of omission, such as forgetting or choosing not to report or record a symptom," they wrote. "Perhaps a more bothersome symptom is the focus of the clinical encounter, and other less onerous symptoms (e.g., glare) are not discussed (or documented). However, even for the exclusive sensitivity analysis, we show that the ESQ and the EMR are inconsistently documented."

While discrepancies in patient- and provider-reported documentation were relatively harmless and did not directly impact patient safety, their existence does raise questions about data accuracy and completeness.

ROOT CAUSES OF EHR DOCUMENTATION PROBLEMS

The benefits of EHR use more generally range from timely access to clinical data and alerts to avoid medical errors to care coordination and improved billing and coding. EHR documentation is the means of realizing these benefits.

"Documentation is often the communication tool used by and between providers. Documenting a patient's record with all relevant and important facts, and having that information readily available, allows providers to furnish correct and appropriate services that can improve quality, safety, and efficiency," the Centers for Medicare & Medicaid stated in a 2015 fact sheet on EHR technology.

In that same guidance, the federal agency identified a handful of common EHR challenges that healthcare organizations and providers need to address. For EHR documentation in particular, these challenges include an inability to log clinicians entering data, cloning data from record to record, and upcoding to receive higher payment.

A year later, CMS released guidance focused specifically on preserving EHR documentation integrity with an emphasis on helping prevent fraud, abuse, and improper payments.

"Providers and others should use program integrity-related EHR software features and capabilities to ensure the integrity of the EHR documentation. Some EHR features may create information integrity concerns; however, providers and others can mitigate these concerns by implementing proper policies and processes," the federal agency concluded.

Where the CMS recommendations for EHR documentation integrity fall short is in identifying and remediating the root cause of these inaccurate, incomplete, or unreliable information within a patient's EHR.

Around the same time, both the American Medical Association (AMA) and American Medical Informatics Association (AMIA) (among others) set out to improve future EHR use by recommending changes to EHR design that address the causes of poor EHR documentation.

For the latter, the first area of EHR improvement necessary involved simplifying and speeding documentation and included two recommendations germane to EHR documentation improvement.

The first was decreasing data entry burden on clinicians by allowing other members of the care team to enter data into the EHR:

"Physicians' time investment in patient care documentation has doubled in the last 20 years, by some measures, possibly consuming up to half of a physician's day. Time requirements for nursing documentation have also changed, as has documentation workflow. The growth in documentation burden is associated with changes in Medicare reimbursement rules, potentially overly strict interpretations of those rules by compliance officers, concerns about malpractice litigation, and other factors. The introduction of EHRs has magnified these problems and the amount of time providers spend on documentation."

AMIA cited the increasing documentation burden on clinicians as the impetus behind the use of copy-and-paste functionality and the resulting bloat in EHR documentation.

"Clinicians remain uncertain regarding who can and cannot enter data into each patient's record, placing a tremendous data entry burden on providers, the most expensive members of the care team. Clinician time is better spent diagnosing and treating patients," the association argued. "Regulatory guidance that stipulates that data may be populated by others on the care team, including patients, would reduce this burden."

The second recommendation called for separating data entry from data reporting:

"Templates are often used to capture data as discrete observations, in place of free-text narratives. The resulting documentation sometimes has limited relevance to the visit being documented, and important aspects of patients' stories can only be effectively captured by narratives. Compared to human narrative, purely coded templates neither distinguish informational wheat from chaff, nor capture the subtle details of each patient's unique circumstances. Further, coded templates impede effective clinician communication."

According to AMIA, EHR documentation requirements were responsible for making structured data preferable to unstructured data.

Similarly, AMA released guidance for improving EHR usability that included an emphasis on reducing clinical documentation demands on clinicians.

The first of eight total recommendations centered on improving physician-patient interactions by removing EHR technology and data entry as an obstacle to face-to-face communication. AMA traces the problem to EHR design not based on clinical workflows:

"The ways that EHRs structure information, process data and generate clinical reminders (e.g. "popups") too often detracts from physician time with a patient. For EHR users, inflexible software with cumbersome menus or poor graphical user interface configurations leads to excessive clicking and scrolling which increases the administrative time spent during patient visits compared to use of paper charts. Contributing to this problem, many existing EHRs grew out of practice management systems, in which billing and claims are the primary focus and performed by nonclinical staff whose workflow requirements differ significantly from clinicians."

In a similar vein, AMA also called on EHR developers to focus on EHR designs that help reduce the cognitive workload existing systems impose on end users:

"Today's EHRs create a tension between unstructured and structured data that many physicians believe degrades the quality of their clinical care narrative. This tension has compelled physicians and others to enter data into EHRs without regard to the value, or lack thereof, created through this substantial additional work. The overall workload - reading, writing, thinking and navigating the system - in EHRs is not well balanced. Many physicians find that the quality of the clinical narrative in paper charts are more succinct and reflective of the patient's perspective and physician's thought process. In contrast, unlike paper charts, EHRs favor structured data capture in the form of drop-down menus and templates that can interfere with the creation of a coherent narrative."

The solution to these and the other EHR usability challenges comes down to user-centered design with clinicians provide substantial input into how developers go about designing their EHR technology.

SOLUTIONS FOR IMPROVING EHR DOCUMENTATION

Solutions to clinical documentation problems fall into two general categories: technical and administrative.

Beginning with the latter, healthcare organizations of any side need to establish business practices supporting quality clinical documentation. And the guidance from AHIMA guidance from 2013 still holds true in laying out for primary conditions necessary for maintaining EHR documentation integrity:

  • Desire and commitment to conduct business and provide care in an ethical manner
  • Purchasing systems that include functions and capabilities to prevent or discourage fraudulent activity
  • Implementing and using policies, procedures, and system functions and capabilities to prevent fraud
  • Inclusion of an HIM professional such as a record content expert on the IT design and EHR implementation team to ensure the end product is compliant with all billing, coding, documentation, regulatory, and payer guidelines

As for technical solutions to EHR documentation pitfalls, the AHIMA recommendations align well with those identified by CMS in 2016, both of which call for capabilities in EHR technology that require user authentication and access management, allow for the tracking of user activities (e.g., audit logs), and restrict alterations to user auditing files.

These technical recommendations, however, fail to address EHR documentation challenges to clinical productivity. A growing body of evidence points to the potential for natural language processing technologies to reduce burdens associated with clinical documentation.

"We found that a pure protocol of NLP Entry as well as hybrid protocols (involving both NLP Entry and Standard Entry) showed promise for EHR documentation, relative to Standard Entry alone (Standard-Standard Entry)," Kaufman et al. observed in JMIR Medical Informatics.

In an interview CHRISTUS Health in early 2016, CMIO Luke Webster credited natural language processing as a key component of clinical documentation improvement efforts at the Texas health system. In many cases, physicians were unaware that their dictation was running through a voice recognition engine and being transcribed before a human transcriptionist reviewed and finalized the documentation.

"One of the hopes (and obviously the plans that we have in place) is to leverage that foundational technology to improve clinical documentation real-time, such as prompting providers as they document," said Webster.

While natural language processing could ease EHR documentation burdens on providers, it requires the implementation of more technology. An easier solution could be in the form of rethinking workflows for clinical documentation as Mississippi's Memorial Hospital of Gulfport CMIO David Northington, MD, explained last year:

"Before going into a patient's room, I sit down in front of the computer, I view other physicians' notes (inpatient/outpatient), I review the results on the patient, I put in my mind what this patient should look like if I hadn't seen them before. Then I go into the patient's room and talk about my findings, concerns, and listen to what they are telling me. Then I go back out, open up the chart, start my ordering and documentation process before finishing it. So it's three times that I'm really working on this patient to create one document. You can imagine the future - and we're starting to see this in some rooms we're working with - doing this all in front of the patient with an interactive system that is recognizing the conversation that we're having with the patient and showing them what's going on from the CAT scans or lab reports, and as you walk out the door that document is completed. You're learning, studying, and communicating with patients.

That's the next generation of the EHR. That's a much more efficient way that takes it down from doing it three times to one time. That hasn't been completely embraced yet, but that's where I imagine we're going when you really start getting return on investment."

A combination of these administrative and technical solutions will be necessary to ensure that EHR documentation benefits patients in the here and now as well as those receiving care in the future.

Praxis EMR - Why Templates Don't Work Articles - American Academy of Orthopaedic Surgeons

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 begin_of_the_skype_highlighting (312) 642-5616 end_of_the_skype_highlighting 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.
Praxis EMR - Why Templates Don't Work Articles - Cooperative of American Physicians

Do Not Let an EHR Template Determine Your Standard of Care

If you are contemplating the purchase of an Electronic Health Record (EHR) system, it is important that you and/or your physicians take time to review each system's medical record templates. Many systems have predetermined templates that allow minimal customization. Other systems offer greater customization options for a higher price. The important thing to keep in mind is that an EHR template is nothing more than a boilerplate, written by a third party or "expert" to input clinical data. The inflexibility of this template presents series of fundamental problems that will crop up during everyday use, specifically:

  1. The template is someone else's thought process and incorporates assumptions about what you think and how you should practice medicine.
  2. The template is generated to cover a wide variety of practices and encounters, making it very general.
  3. Templates tend to take a cookie-cutter or one size fits all approach, with no regard for age appropriateness or target patient population.
  4. Some templates allow very little room for free text, thus limiting the information wich can be entered.

One of the biggest dangers presented by templates is that they may set the standard of care to wich the physician may be held. Acceptance of an EHR template may be viewed as your standard of care. Therefore, when choosing an EHR system, physicians should consider the following:

  1. Does the system allow you to use your own forms?
  2. Can you mirror the way you practice today and improve it?
  3. What is the cost for customization of templates?
  4. Does the system have an e-Prescribing function?
  5. Does it provide for secure messaging?
  6. What will the vendor charge for modifying a template?

The bottom line is that you should select an EHR system that best fits the needs of your practice or medical group, and that closely mirrors your practices current templates.

Authored by
Ann Whitehead, RN, JD
CAP Risk Management & Patient Safety Department

Praxis EMR - Why Templates Don't Work Articles - UC Davis

UC Davis study finds e-medical records have varying effects on productivity

The introduction of electronic medical records in hospitals and clinics - dubbed the "silver bullet" of health care reform - appears to have varying effects on different types of primary care physicians, a UC Davis study has found.

"Our research suggests that a 'one-size-fits-all' design does not work - the ideal technology design should vary by physicians' requirements and work-flow demands," said Hemant Bhargava, associate dean and professor of management and computer science at the UC Davis Graduate School of Management.

Bhargava and his research colleagues recently completed a study of a multimillion-dollar information technology project installed at six primary care offices from 2003 to 2006. The offices were part of a large primary care physician network affiliated with an academic medical center.

The study, one of the first to measure the impact of electronic medical record-keeping on doctors' productivity, was conducted with Abhay Mishra, an assistant professor of health administration at Georgia State University, and research assistant Shuang Liu, a Ph.D. student in applied mathematics at UC Davis.

The system that was studied digitized patient records and allowed for electronic prescriptions and messaging.

The federal government has shown its support for developing electronic health records by setting aside $19.2 billion in stimulus funds to help pay for such conversions across the country.

"Prior to our study," Bhargava said, "there was controversy regarding the benefits of health care IT investments. In fact, there was some anecdotal evidence that these technologies reduced physician productivity."

For the study, researchers analyzed the impact the technology had on physician productivity, collecting data on work hours and output before and after the introduction of EMR technology. The data was collected for about 100 physicians spread across three primary care categories - internal medicine, pediatrics and family practice - and six clinics.

The researchers found that the initial implementation of the EMR system resulted in a 25 percent to 33 percent drop in physician productivity. While significant, the drop was anticipated, Bhargava said.

"Initially, physicians and their staff had to learn the system," he explained. "After a month of utilization, physicians and their staff became more comfortable with the technology and productivity overall increased to just below starting levels, with interesting variations by unit."

Over the next few months, the researchers found that the impact of the new technology on productivity varied by physician group. Internal medicine units adjusted to the new technology and experienced a slight increase in productivity. In contrast, pediatricians and family practice doctors did not return to their original productivity levels and experienced a slightly lower productivity rate.

"These differences by unit suggest that there is a mismatch between technology design and the work-flow requirements and health administration expectations for individual care units," Bhargava said.

The findings, he explained, can be more easily understood by breaking EMR technology use into two categories - information review and information entry.

The use of electronic medical records makes information review - patient history, notes from previous visits, charts of test data and radiological images - more efficient. These features are useful to internal medicine doctors, who tend to see a greater proportion of ill patients.

In contrast, pediatricians' work tends to involve more information entry and documentation for which EMR technology can be more time-consuming.

Bhargava suggests vendors and medical centers consider implementing different versions of electronic record keeping systems, tailoring the user interface, information entry and visualization features for different groups of physicians.

About UC Davis

For more than 100 years, UC Davis has engaged in teaching, research and public service that matter to California and transform the world. Located close to the state capital, UC Davis has more than 32,000 students, more than 2,500 faculty and more than 21,000 staff, an annual research budget that exceeds $684 million, a comprehensive health system and 13 specialized research centers. The university offers interdisciplinary graduate study and more than 100 undergraduate majors in four colleges - Agricultural and Environmental Sciences, Biological Sciences, Engineering, and Letters and Science. It also houses six professional schools - Education, Law, Management, Medicine, Veterinary Medicine and the Betty Irene Moore School of Nursing.

Media contact(s):

  • Hemant Bhargava, Graduate School of Management, (530) 754-5961 , hemantb@ucdavis.edu
  • News Service, (530) 752-1930
Praxis EMR - Why Templates Don't Work Articles - KevinMD.com

Do electronic medical records decrease liability risk?

Doctors are pushed to adopt electronic medical records harder than ever before.

However, costs are often the prohibitive obstacle, and whether the current generation of EMRs improve patient care remains in question.

But what about liability? Surely, more complete, legible medical records would reduce the risk of being sued. Right?

Well, it's not that cut and dry.

In a story from American Medical News, doubts remain as to whether EMRs reduce the risk of being sued. The biggest problem is that most EMR charts are template-driven, meaning that superfluous, and sometimes inaccurate, information often creeps into a documented patient visit.

Several lawyers acknowledge further downsides, including, "the default settings of an EMR could present fewer opportunities for physicians to add information to medical records," and, "EMRs also could provide too much information. For example, risk could increase if the EMR generates alerts or supplementary information and physicians don't act upon them."

(The reference to "adding information" is, I believe, a reference to the fact that EMRs discourage free-texting, as opposed to adding information after the fact.)

Current electronic medical records have a hard time talking to one another, which is essential to realizing their potential to reduce medical errors and improve patient outcomes. Until they do, the effect of EMRs on reducing medical malpractice is tepid at best.

Praxis EMR - Why Templates Don't Work Articles - ModernMedicine

The problem with EHRs and coding

This article originally published in Medical Economics

Key Points

  • Ineffective policies from numerous key organizations have contributed to widespread EHR compliance problems.
  • Well-intended physicians are being victimized when audits reveal their EHRs have allowed non-compliant claims.
  • Audited practices have been fined between $50,000 and $175,000 per physician for their inadvertent infractions.


Today's political and economic environment has focused a spotlight on healthcare reform and the promotion of health information technology in particular. The Obama administration has promised to invest $10 billion per year over the next five years on HIT, including electronic health records. Senator Max Baucus, chairman of the Senate Finance Committee, says HIT represents "the beginning of healthcare reform and a key part of the economic recovery."

The Centers for Medicare & Medicaid Services (CMS) is also exerting increasing pressure on physicians to purchase HIT: financial incentives for using electronic prescribing through 2013 and rising penalties to practices that fail to employ this technology starting in 2012. The administration's stimulus package provides incentives for implementing and using certified EHR systems, while those practices that don't adopt these systems by 2014 will receive reductions in reimbursement.

Health policy advocates justifiably point to a myriad of potential benefits that should result from the widespread implementation of EHRs, from safe storage of health information to electronic sharing of clinical information. The knowledge shared through this access to patients' medical data promises to improve patient safety and reduce costs associated with duplicate and/or unnecessary tests and treatments. Electronic prescribing further promises to reduce medication errors, ranging from drug interactions to misinterpreted handwriting.

Most physicians who introduce EHR systems into their practices seek promised advantages for enhancing quality care and patient safety through the systems' touted data storage and retrieval characteristics. Electronic records offer immediate access to patients' documents and data.

Likewise, most physicians include among their highest priorities the goal of compliant evaluation and management (E/M) coding. Physicians believe they have a right to expect that these sophisticated and costly systems will ensure that they achieve compliant documentation and coding, thereby "making any E/M problems go away."

However, something has gone awry to create an environment that leaves well-intended physicians victimized when government audits reveal their software systems have allowed-even facilitated-submission of non-compliant and potentially fraudulent claims for E/M services. In the midst of increasing storm warnings of non-compliant designs, physicians are increasingly vulnerable to severe financial penalties.

This devastating storm has been developing for many years, often bolstered by an unintended lack of effective policies from several organizations that should have the best interests of physicians, patients, and the healthcare system at their core-organizations such as CMS, the Certification Commission for Healthcare Information Technology (CCHIT), and the U.S. Department of Health and Human Services (HHS), as well as EHR software vendors and physician training institutions (for more information).

Gathering Storm Clouds

Analyses of problems with EHR systems by physicians and their practice managers consistently reveal that the overwhelming preponderance of their challenges relate to the rarely discussed data-entry characteristics of the electronic history and physical (H&P), not to the heralded data-storage and retrieval features of their systems. One physician personally reported that "The software forces me to enter clinical information in a preloaded format; when I see a patient three weeks later, I cannot find any individualized details of the previous visit or understand why I did what I did."

In April 2008, a study published in the New England Journal of Medicine reported similar problems, pointing out that "Notes that are meant to be focused and selective have become voluminous and templated, distracting from the key cognitive work of providing care. Such charts may satisfy the demands of third-party payers, but they are the product of a word processor, not of physicians' thoughtful review and analysis. They may be 'efficient' for the purpose of documentation but not for creative clinical thinking."

The study also reported an example of the consequences of these problems: "A colleague at a major cancer center that recently switched to electronic medical records said that chart review during rounds has become nearly worthless. He bemoaned the vain search through meaningless repetition in multiple notes for the single line that represented a new development . . . Ironically, he has started to handwrite a list of new developments on index cards so that he can refer to them at the bedside."

Too often, these problems have proven insurmountable. At the Second HIT Summit in 2005, Mark McClellan, MD (then the administrator of CMS), reported "40 percent of attempted implementations fail." According to the April 1, 2006, issue of CIO Magazine, "The [Health and Human Services] department itself has acknowledged that the failure rate for EHR system implementation is 30 percent to 50 percent. Some healthcare network providers claim it is as high as 70 percent."

These electronic H&P challenges can manifest in one or more of four interrelated areas:

  1. Integrity of the clinical information recorded
  2. Usability, quality of the clinical care and workflow guided by the record
  3. Malpractice protection
  4. Evaluation and management (E/M) compliance.

When audits reveal lack of compliant documentation generated by physicians using an electronic H&P, the findings can be viewed as the "canary in the coal mine" to warn of additional impending dangers related to data integrity, quality of care, and malpractice protection.

During the last several years, a significant number of articles have pointed out compliance problems intrinsic to the majority of current EHR systems. Chief among these relate to coding engines that fail to consider medical necessity, which CMS describes as "the overarching criterion for payment," and certain types of data-entry functionality that result in "cloned documentation," in which the records of every visit read almost word-for-word the same except for minor variations confined almost exclusively to the chief complaint.

Physicians have long been counseled that a well-documented medical record provides the best defense in the event of a claim of medical liability. The June 2008 issue of the Journal of AHIMA quoted EHR legal expert Patricia Trites on the potential danger of electronic systems that permit copying of near-identical documentation into large numbers of patient records: "From a medical-legal standpoint, what would [lawyers] do when they [see] this chart?" she asks. "They are going to rip it apart."

In 2007, HHS and the Office of the National Coordinator for Health Information Technology (ONCHIT) published an extensive report on "Recommended requirements for enhancing data quality in electronic health record systems." The section that reviews E/M documentation features (and analyzes current certification criteria for these EHR features) advises that "EHRs provide a variety of tools that enable a provider to be more efficient when documenting an encounter . . . These tools include the use of defaults, templates, copying, and others. The report then continues with the warning: "[These tools] can be extremely helpful if used correctly; however, the tools can also open the EHR [system] up to fraud or abuse."

The problem that physicians face is that most current EHR system designs have failed to incorporate protections to ensure the correct use of these shortcut tools. Without such "error proofing," it is not feasible for physicians, while concentrating on patient care, to differentiate the settings in which these various tools can be used compliantly from those circumstances in which their use could lead to pliant or even fraudulent documentation.

The Perfect Storm Converges

Let's summarize. Where are the storm fronts forming this perfect storm coming from? An EHR system "weather map" reveals the following:

  • Physicians whose conventional medical education lacked training in the relationship of compliance to quality care and also failed to provide medical record tools that promote compliant (and efficient) documentation and coding
  • Time constraints imposed by significantly constricted reimbursement environment
  • Powerful incentives for purchase and implementation of EHR systems
  • Software systems that a) may have coding engines that fail to account for medical necessity; b) may have designs that automatically guide physicians to create records with high levels of documented care for every visit; c) may have shortcut documentation tools that create "automated" documents, identified by HHS as "having the potential for fraud and abuse"; and d) therefore consistently derive and recommend submission of high-level E/M codes for almost every patient encounter
  • Accurate Medicare or Office of the Inspector General (OIG) auditors reviewing medical records of the practices whose recently implemented medical records have drawn their attention by consistently submitting claims for high levels of E/M care.

Ms. Grider, Ms. Linker, and Ms. Thurston are three compliance experts who were called in to assist different physician groups during federal and state audits of those groups' electronic H&P records, conducted either by individual Medicare Carriers, Recovery Audit Contractors (RACs), or the Office of the Inspector General of the HHS. In each of the four cases, the audits revealed pliant E/M claims that were submitted as a consequence of physicians using their EHRs in accord with their particular designs for E/M documentation and coding.

The four practices employed between 1 and 10 physicians. The government audit evaluated between 20 and 100 charts per physician, and the percentage of charts failing audit for each physician ranged from 20 to 95 percent.

As a result of these findings, each practice was assessed a significant penalty for pliant documentation and coding. For the practice with the lowest percentage of failed audits, the final determination required repayment to Medicare of approximately $50,000 per physician. For the other three practices, the repayments ranged from $150,000 to $175,000 per physician. For at least one of the practices, the audit also imposed an administrative requirement of prepayment review for 100 percent of all future Medicare claims.

Even though each practice was using a different EHR, there was remarkable similarity in the design and functionality limitations identified as the causes of their compliance problems:

  • All of the systems had designs that failed to meet all of Current Procedural Terminology's and Documentation Guidelines for Evaluation and Management Services' published requirements for compliant documentation of medical history, physical examination, medical decision-making, and nature of the presenting problem(s) (which is the E/M system's measure of medical necessity)
  • Each of the systems included three or more types of data-entry functionality that has been consistently identified as having the potential to promote non-compliant or even fraudulent documentation
  • The E/M coding engines of all four systems failed to consider the three levels of risk in decision-making, failed to consider medical necessity in determining appropriate code levels, and failed to recognize the critical role of medical necessity in guiding medically indicated levels of care, documentation, and coding.

The authors who reviewed the records and audits for these practices observed that while many EHRs present one or more mechanisms to automate documentation of required history and examination elements, from both the compliance and the data-integrity perspective, automation is not documentation.

The added danger is that such automated documentation can also distort physicians' optimal care and workflow, and destroy data integrity. For example, in one of the reviewed practices, use of the EHR's preloaded macros for the physical examination actually created automatic documentation indicating that females had received prostate exams and males had negative pap smears.

The outcomes of these federal audits have been devastating, emotionally as well as financially, for the physicians and staffs of the practices involved. The failure of the EHR systems to provide for compliant E/M documentation and coding, as well as protections against overcoding and undercoding, led to statistically remarkable increases in the percentage of claims submitted with level 4 and level 5 codes. This increase drew the attention of government auditors, and the medical records created using these systems most often could neither support the levels of care submitted (primarily due to documentation shortcuts creating "cloned" records) nor the medical necessity for providing such high levels of care (due to failure to consider the nature of the presenting problem).

The overall conclusion derived from these reviews is that electronic record systems should provide sophisticated designs and functionality based on physicians' optimal patient-care workflow. They should be required not only to guide physicians in providing high-quality care and creating compliant documentation, but to protect against designs that have the potential to disrupt optimal care and/or generate non-individualized and non-compliant medical documents.

How to Avoid the Perfect Storm

The causes of this perfect storm must be identified and eliminated. In response to these imminent dangers, practices that are currently using EHRs should obtain assistance from E/M compliance experts. They should insist that their vendors eliminate all non-compliant documentation and coding functionality related to their systems' electronic H&P, replacing such features with effective documentation tools that are usable, efficient, and compliant.

Similarly, when practices investigate the possibility of purchasing an EHR system, they should include experts in compliance and quality documentation on their evaluation team. As a condition for purchase, they should also require that these systems be usable for their physicians, efficient, contain only compliant documentation and coding tools, provide only for recording of individualized, meaningful, and reliable clinical information, and promote the quality-care process.

Figure 1 illustrates a sample blueprint for certifying that electronic H&P designs are "operable as well as interoperable." It presents standards that meet physicians' common criteria for effective medical records. These standards advocate for creative designs that not only promote quality care and meaningful documentation, but that protect against non-compliant documentation and distorted care. Physicians and practice managers would do well to require that EHR systems meet such criteria before purchase or implementation.

The Role of EHR Stakeholders

It is incumbent upon physicians' professional societies to seek the assistance of compliance experts and initiate policies that require corrective action for the underlying causes of these currently identified EHR system problems. This effort can include the following initiatives:

  • Physician training institutions (medical schools and residency programs) should reinforce their current training for a comprehensive medical evaluation with training in E/M compliance and with provision of efficient documentation tools that physicians can use to provide these comprehensive levels of care within the time constraints of residency and medical practice
  • EHR software vendors must provide systems whose design and functionality have the capability to guide physicians to effective care and compliant documentation, including elimination of all potentially non-compliant functionality. Further, if CCHIT does not incorporate criteria to certify these requirements, the medical societies themselves may need to establish them and provide substantive review
  • CMS must meet its own standards for compliance by requiring its fiscal intermediaries (i.e., carriers) to employ only auditing and coding tools that are compliant with the established standards in CPT and Documentation Guidelines. It must also institute a policy requiring designs to be compliant and audit-protected as a condition for EHR systems to be eligible for CMS's payment-incentive programs
  • CCHIT has a responsibility that certification should provide meaningful protection to physicians (for systems that ensure compliance) and patients (for systems that guide and promote an optimal-care process). It should therefore incorporate high-quality criteria for functionality and compliance of the electronic H&P. These and all other criteria should be reviewed and authenticated by a consortium of medical societies and coding-compliance societies
  • HHS and the ONCHIT should modify their focus, supplementing concerns for potential fraud and abuse with an even greater focus on standards that protect physicians from non-compliant software designs and from educational approaches that impair their abilities to practice the optimal-care process that is the core of their training and their ethic.

A Clarion Call

As the Obama administration provides incentives for the much-needed adoption of electronic health records, it must provide protections that guarantee not only the sharing of information, but also that the process of gathering this information and the quality of the information recorded are optimized. Recent audits by federal agencies confirm the warnings about E/M compliance dangers accompanying documentation shortcuts introduced by many current EHR software designs. These audits are a clarion call for stakeholders to eliminate the problems they have created, however unintended. Stakeholders must structure an environment in which physicians receive appropriate training with effective and compliant documentation tools, in which software systems provide only compliant designs and protect against improper documentation, and in which governmental agencies eliminate non-compliant practices in their own organizations and mandate compliant designs in the software systems they are advocating and promoting.

Stephen Levinson, MD, is the author of the books Practical E/M and Practical EHR. He has long focused on the interplay between compliance and quality patient care, medical ethics and integrity, and the health of the healthcare system.Deborah Grider is president of the American Academy of Professional Coders National Advisory Board. Robin Linker is executive director of operations and auditing for the Association of Healthcare Auditors and Educators, and CEO of Robin Linker & Associates Inc. Susan Thurston is executive director of education for the Association of Health Care Auditors and Educators, and CEO of Coders Connection Inc.

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Praxis EMR - Why Templates Don't Work Articles - The New England Journal of Medicine

Off the Record - Avoiding the Pitfalls of Going Electronic

Many of us remember searching frantically for a lost chart or misfiled laboratory result in the wee hours of the morning as we cared for a sick patient in the emergency ward, or requesting in vain the most recent note from a specialist about a patient who returned to our office after a consultation. The ultimate goal of the electronic medical record - a technological solution being championed by the Bush administration, the presidential candidates, and New York Mayor Michael Bloomberg, as well as Google, Microsoft, and many insurance companies - is to make all patient information immediately accessible and easily transferable and to allow its essential elements to be held by both physician and patient. The history, physical exam findings, medications, laboratory results, and all physicians' opinions will be collected in one place and available at a single keystroke. And there is no doubt that these records offer many benefits. We worry, however, that they are being touted as a panacea for nearly all the ills of modern medicine. Before blindly embracing electronic records, we should consider their current limitations and potential downsides.

As we have increasingly used electronic medical records in our hospital and received them from other institutions, we've noticed several serious problems with the way in which notes and letters are crafted. Many times, physicians have clearly cut and pasted large blocks of text, or even complete notes, from other physicians; we have seen portions of our own notes inserted verbatim into another doctor's note. This is, in essence, a form of clinical plagiarism with potentially deleterious consequences for the patient. Residents, rushing to complete numerous tasks for large numbers of patients, have sometimes pasted in the medical history and the history of the present illness from someone else's note even before the patient arrives at the clinic. Efficient? Yes. Useful? No. This capacity to manipulate the electronic record makes it far too easy for trainees to avoid taking their own histories and coming to their own conclusions about what might be wrong. Senior physicians also cut and paste from their own notes, filling each note with the identical medical history, family history, social history, and review of systems. Though it may be appropriate to repeat certain information, often the primary motivation for such blanket copying is to pass scrutiny for billing. Unfortunately, these kinds of repetitive notes dull the reader, hiding the important new data.

Writing in a personal and independent way forces us to think and formulate our ideas. Notes that are meant to be focused and selective have become voluminous and templated, distracting from the key cognitive work of providing care. Such charts may satisfy the demands of third-party payers, but they are the product of a word processor, not of physicians' thoughtful review and analysis. They may be "efficient" for the purpose of documentation but not for creative clinical thinking. Similarly, electronic medical records can reproduce all of a patient's laboratory results, often dropping them in automatically. There is no selectivity, because it takes human effort to wade through all the data and isolate the information that is pertinent to the patient's current problems. Although the intent may be to ensure thoroughness, in the new electronic sea of results, it becomes difficult to find those that are truly relevant.

A colleague at a major cancer center that recently switched to electronic medical records said that chart review during rounds has become nearly worthless. He bemoaned the vain search through meaningless repetition in multiple notes for the single line that represented a new development. "It's like `Where's Waldo?'" he said bitterly. Ironically, he has started to handwrite a list of new developments on index cards so that he can refer to them at the bedside.

True, handwriting in charts is sometimes illegible and can lead to miscommunication. It might seem that the printed (or at least typed) word, which we are all conditioned to respect, would always be more definitive and have more impact than text written by hand. But we have observed the electronic medical record become a powerful vehicle for perpetuating erroneous information, leading to diagnostic errors that gain momentum when passed on electronically.

An advertisement from a health care network touts the electronic medical record as the avatar of "High Performance Medicine." The ad, whose headline reads "Medicine That Doesn't Forget," shows a country doctor carrying a black bag. "Remember when physicians knew everything about their patients and carried all that they needed in a little black bag?" the ad asks. The electronic medical record, it asserts, "is the modern physician's equivalent of that little black bag. Only better." But the attempt to link this form of technology with nostalgia for the family doctor who spent time in extended conversation and care seems rather incongruous. Indeed, this humanistic depiction of the electronic medical record contrasts sharply with the experience of many patients who, during their 15-minute clinic visit, watch their doctor stare at a computer screen, filling in a template. This is perhaps the most disturbing effect of the technology, to divert attention from the patient. One of our patients has taken to calling another of her physicians "Dr. Computer" because, she said, "He never looks at me at all - only at the screen." Much key clinical information is lost when physicians fail to observe the patient in front of them.

The worst kind of electronic medical record requires filling in boxes with little room for free text. Although completing such templates may help physicians survive a report-card review, it directs them to ask restrictive questions rather than engaging in a narrative-based, open-ended dialogue. Such dialogue can be key to making the correct diagnosis and to understanding which treatment best fits a patient's beliefs and needs. One pediatrician told us that after electronically verifying use of seat belts, bicycle helmets, and other preventive measures, she has scant time to explore clinical issues. Electronic medical records may help to track outcomes and adherence to guidelines, but they may also force doctors to give "standard" rather than "customized" care.

These problems, we believe, will only worsen, for even as we are pressed to see more patients per hour and to work with greater "efficiency," we must respond to demands for detailed documentation to justify our billing and protect ourselves from lawsuits. Though the electronic medical record serves these exigencies, it simultaneously risks compromising care by fostering a generic approach to diagnosis and treatment.

We are not Luddites, opposed to all technological interventions; we can see that electronic medical records have many benefits. Mountains of paper are replaced by the computer screen, with rapid access to complete and organized information, with risks such as dangerous drug interactions automatically flagged. But we need to learn how to use this powerful tool in the way that is best for patient care, regardless of whether it's the most "efficient" way.

We should instruct house staff that they must create independent, personal notes by talking to the patient and verifying the medical history themselves. We should discuss with payers what constitutes real documentation of time and effort rather than sleight of hand. We should use electronic formats that require us to select and insert specific, relevant laboratory results.

Perhaps most important, we should be cautious in using templates that constrain creative clinical thinking and promote automaticity. We must be attentive to the shift in focus demanded by electronic medical records, which can lead clinicians to suspend thinking, blindly accept diagnoses, and fail to talk to patients in a way that allows deep, independent probing. The computer should not become a barrier between physician and patient; as medicine incorporates new technology, its focus should remain on interaction between the sick and the healer. Practicing "thinking" medicine takes time, and electronic records will not change that. We need to make this technology work for us, rather than allowing ourselves to work for it.

Drs. Hartzband and Groopman report holding stock in Microsoft and Google.

Source Information

Dr. Hartzband is an endocrinologist at Beth Israel Deaconess Medical Center and an assistant professor of medicine at Harvard Medical School, and Dr. Groopman is a hematologist–oncologist at Beth Israel Deaconess Medical Center and a professor of medicine at Harvard Medical School - both in Boston.

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