Using the F-word when it comes to EHRs

Not long ago, Secretary of Health and Human Services Sibelius and US Attorney General Holder issued a stern warning to healthcare providers who are using electronic health records (EHRs).  The federal officers maintain there has been an alarming increase in the charges to Medicare in institutions where EHRs have been implemented, and they warn that those behaviors will be treated as “fraud,” an illegal gaming of the system to increase reimbursement to those institutions and their physicians.

Let’s revisit billing for healthcare services.

Charges for healthcare services are submitted on “universal” billing forms, which utilized both alphabetic entries (e.g. the patient’s name) and numerical entries (practically everything else).  There is a lot of information on a billing form, but the meat of it is the list of diagnostic and treatment codes, which are standard numbers assigned by the International Classification of Diseases (ICD) and Current Procedural Terminology (CPT).  Those codes determine how much the institution and the physician will be paid.

In the traditional chart, physicians entered diagnoses and treatments using handwritten words.  In order for those words to be used for billing Medicare or any other payer, they had to be converted to the numbers assigned to them by ICD/CPT.  That conversion was accomplished by “coders”, people trained in the terminology of ICD/CPT, but not necessarily or usually in a clinical discipline.

It is important to understand two things here.  The first is that, although ICD/CPT are creations of organized medicine, the terminology within them and that employed by doctors on a day-to-day basis can differ significantly.  The second is that most doctors have ordinarily regarded “charting” to be a low priority task, one that is to be accomplished as rapidly as possible so that the  next patient can be seen, the next task initiated.  The upshot is that doctors have developed a system of taciturn entries employing abbreviations, acronyms, and symbols to get their message across in the shortest possible time.

One of the most extreme routine progress note entries was that employed by the chief resident in neurosurgery, when I was an intern on his service.  For most of his patients, throughout sometimes prolonged hospitalizations, the progress note each day would be “ᶲΔ”, “phi” being the mathematical symbol for “null”, “delta” the scientific symbol for “change”, therefore “no change”.

The neurosurgeon’s note was egregious.  Most physician progress notes actually contain valuable information, but when it is expressed in symbols, etc., that may be perfectly understood by doctors, it is not information that can be coded.  The diagnoses therein do not contribute to the severity of illness or services, therefore, and Medicare and insurors benefit from a non-contractual but nevertheless substantial discount.

Before the Affordable Care Act (ACA, ObamaCare), there was the American Recovery and Reinvestment Act of 2009 (ARRA).  ARRA mandated the utilization of EHRs and reinforced that mandate with a series of financial consequences for providers that progress with time from positive (bonuses) to negative (penalties).

There are dozens of EHR products on the market, and I have seen a relative few.  All those however, and I suspect those I have not seen, incorporate standard terminology that corresponds to ICD/CPT.  Now the doctor, without sacrificing time-efficiency, can incorporate fully informative entries into the chart that will satisfy the criteria by which the coders are bound, and the result will be a universal billing form that more accurately describes what was wrong with the patient and what the institution and doctor did for him or her.

The charges to Medicare will be increased thereby.

The Secretary and AG allege that providers are “cloning” EHRs, somehow documenting services that were not actually provided.  If so, that deserves the “f-word” and all the legal consequences that go with it.  I think any such behavior represents a vanishingly small fraction of the increase in charges they have observed, though.  I think they are seeing the consequences of ARRA EHR mandate, and I believe they will see more and more as EHRs become more widely utilized.

This is a completely predictable outcome.  One of the attributes touted for EHRs is the standardization and completeness of the medical record, creating one that can be shared by multiple users and be meaningful for all.

I am confident that HHS/Medicare and the insurance companies will find ways to neutralize the resulting increases in charges.

Richard Patterson is a surgeon who blogs at DailyDudley.

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