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Join us for an insightful conversation with Erica E. Remer, a physician and clinical documentation specialist, as we explore the challenges and pitfalls of electronic medical records (EHRs). Erica delves into the impact of copy and paste (C&P) practices and the degradation of clinical documentation on patient care and quality metrics. Discover the reasons behind the prevalence of bad documentation habits and explore potential solutions, including reciprocal auditing and a documentation timeout. Don’t miss this engaging discussion on the importance of responsible and effective clinical communication with a seasoned expert in the field.
Erica E. Remer is a physician and clinical documentation specialist. She is creator, icd10md Documentation Modules for Providers with CME.
She shares her story and discusses her KevinMD article, “Fixing the broken system: Improving clinical documentation in health care.”
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Erica Remer. She’s a physician and a clinical documentation specialist. Her KevinMD article is titled “Fixing the broken system: improving clinical documentation in health care.” Erica, welcome to the show.
Erica E. Remer: Thank you very much, Kevin. Good to be here.
Kevin Pho: We’ll get to the article in a little bit. First off, briefly share your story and journey to where you are today.
Erica E. Remer: Thanks. Well, I was in practice for 25 years, and my expertise was always in documentation. I was sort of the liaison between the coders and my colleagues, trying to make sure that we got paid appropriately for what we did. At one point I was a half-time emergency physician and a full-time mom, and my boss said she had seen a position that looked like it was right up my alley. So I became the physician advisor for a large multi-hospital system.
When I was interviewing for it, it was the first time it ever occurred to me that the hospital got paid too. I knew exactly nothing about what the documentation needed to do to support the billing on the hospital and facility side. My boss gave me three months to get up to speed, and I learned it, and it’s really fascinating. I did that for four years, and then I went out to be a consultant. I’m a consultant now, and I teach doctors how to document.
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Kevin Pho: Now, what is it about clinical documentation that really piqued your passion? Because I talk to a lot of physicians, and honestly, documentation is not very high on their list. Documentation is obviously a passion for you, so what is it about documentation?
Erica E. Remer: Well, you know, it’s interesting. I think that there are two kinds of people: the kind who really liked science and math and the kind who really liked social studies and English. I think that if you like social studies and English, you’ll understand that documentation is really important for us to convey what’s going on with the patient.
The government is talking about documentation as a burden, and to me, I think that it’s a responsibility. It’s how we convey to our colleagues what’s going on with the patients and how we take care of patients. So I think it’s really important. The fact that the United States happens to use it for reimbursement is really just the problem.
Kevin Pho: Tell me about the evolution of documentation. You mentioned you’ve been practicing for 20, 25 years, and now you’re a consultant in clinical documentation, so I’m sure that you’ve seen the evolution of documentation as we transitioned into the electronic age. From a high-level view, tell me about that evolution of documentation over the decades to where it is today.
Erica E. Remer: Well, I understand that you often have medical students and residents who actually watch your show. In the olden days, we actually used to have to write things out. So what happened is we had a lot of problems with legibility and with finding pieces and parts of the chart, because it was not so easy; you couldn’t just click on a tab and open it up. People in those days wouldn’t do copy and paste, the reason being it would take much longer to copy over yesterday’s entry into today’s. So it was a matter of convenience; you didn’t want to waste your time. In the olden days, when we had it on paper, you couldn’t read it, but it actually told the story.
In 2011, the government actually offered money to the hospitals to implement an electronic medical record, and everybody said, “14 million dollars? Yes, thank you, please.” So they implemented medical records that were electronic, and it was the infancy, right? When it first started, their focus was on trying to make sure that people hit all the points that they needed for billing, and we started losing the story. People started just clicking on boxes, and instead of telling a cogent story, it was sort of more haphazard. Then they also recognized that copy and paste was a time-saving tool.
In fact, when I became a physician advisor, I recognized that copy and paste was a big problem, and I came to the administration, and they said, “Well, why don’t we just turn the function off in the electronic medical record?” And I said, “Oh, OK.” Then I went and sat with the residents and watched how they managed their documentation. What they would do is Control-A to copy everything, and then they would Control-X, they’d put it into a Word document, they’d play around with it, and then they’d put it back into the medical record. I realized they weren’t using the copy-forward function in the medical record at all, so turning off that function was not going to solve the problem of copy and paste.
One of the things that I actually do when I’m teaching doctors is I say, “OK, honestly, raise your hand if you love the convenience of copy and paste.” Everybody raises their hands. Then I say, “OK, now raise your hand if you love reading other people’s copy and paste.” Everybody kind of looks at me sheepishly, and they realize that my copy and paste for my convenience is somebody else’s “I can’t stand reading somebody else’s copy and paste.” So you really need to try to get it into a culture. You need to get the whole institution to have a culture of recognizing that documentation is important to tell the story of the patient and to be able to further their medical care.
Kevin Pho: And you talk more about copy and paste in your KevinMD article titled “Fixing the broken system: improving clinical documentation in health care.” Now tell us, how did your article come together?
Erica E. Remer: Well, anybody who knows me knows I’m actually a pretty well-known consultant in the documentation field, and I write about documentation a lot. There are so many places and parts. The problem is that we’re never really taught how to document. We learn by legend, so our attendings will teach us, but nobody ever taught our attendings how to document, so everybody’s kind of stumbling through it.
I’m actually the course director of a two-day course for people who’ve gotten in trouble with their medical boards. They come in, they’re mandated to be there, and they’re not happy. They sit through it; I have a corporate compliance officer, I have lawyers, and multiple people and myself speak to these folks. One after another, as they’re filing out, when we do it in person as opposed to remote, they say to me, “This was the most amazing course. Why did no one ever teach us this before?” My answer is always the same: I don’t know, because to me it’s obvious that you want people to be able to document to tell the story and to be efficient at doing it. Because nobody is Dr. House, where they have a whole week to take care of one patient with three minions doing their bidding. Everybody is busy, and you want them to be efficient. I want people to know that they can document well, and I want to try to help them be efficient and effective at doing it.
Kevin Pho: Now, from all the courses that you’ve taught and the clinicians that you’ve talked to, what would you say are the biggest gaps in knowledge that these physicians come to you with? What’s the biggest light bulb moment that they have when you teach them?
Erica E. Remer: That’s an interesting question, because what happens is not everybody has the same gap, and not everybody has the same goal in getting them to document well, right? When I was an emergency physician, medicolegal was very important to us, making sure that you used the word “alleged” often, because you wanted to make sure that you didn’t cross over a legal line and make assumptions about patients being guilty. You wanted to make sure that you were covering yourself if there was a bad outcome.
But then when you’re in the hospital setting, their concern is making sure that you meet medical necessity, because if the patient doesn’t meet medical necessity, if you haven’t demonstrated that they need to be admitted to the hospital, then you have no billable service, right? And then for a lot of providers, their concern is making sure that they get paid.
I’m sure you’re aware, but maybe some of the people who are watching are not aware, that in 2021 there was a change in the evaluation and management professional fee components that were necessary for the outpatient office side, and in 2023 it actually moved into the hospital. It used to be that you had to do history, physical, and complexity of medical decision making, and fortunately the AMA worked with CMS, and they decided that, you know what, it really is all about the medical decision making. So now medical decision making and/or time are the key components.
What that did was help me when people had an issue with understanding how to document for their own professional fee. It has now aligned the interests of the hospital and the physician, so everybody needs to make sure that they’re documenting how sick and complex the patient is and why they’re doing what they’re doing, and then making sure that other people can tell that from their documentation.
Kevin Pho: I’m an internal medicine primary care physician. So in my world of outpatient primary care, what are some of the biggest improvements that we can make that would have the biggest impact?
Erica E. Remer: Well, there are several things that you can do. First of all, people misunderstand, and they think that they need to list every single condition the patient has ever had. So you’ll read the first sentence, and it can be a laundry list of all the medical problems the patient has ever had, and hardly any of them are relevant. I think that the first thing you can do is what I call setting the table, which means that you put in the ones that are relevant. If a patient’s coming in complaining of left-sided chest pain, then the fact that they had an upper lobectomy for cancer and the fact that they had a CABG are relevant in the context of that chief complaint.
So in telling your HPI, have the context and then tell the story. I think people should think kind of algorithmically: They’re asking questions, they’re trying to rule out or rule in, and they’re going down a path, so make sure that other people understand their thought process.
The next most important thing is when you’re using your electronic medical record, make sure you edit your templates. Everybody has their normals, and if you don’t edit them out when you haven’t done it or it’s not normal, then it’s not telling the story.
The most important thing, of course, is your medical decision making and explaining why you’re doing what you’re doing. It doesn’t have to be long, but it has to tell the story. If you’re changing somebody’s medications, prescription drug management actually puts you into the moderate-risk category in medical decision making. But you can’t just say “see med list” or “no changes.” You need to actually explain that you thought about this patient: “I’ve asked them about what’s going on with their medications. They’re not having any side effects. It seems to be controlling whatever the chronic condition is, so I’m not going to be changing the medication,” or “I am going to be increasing the dosage,” or “I’m going to be adding something.” Whatever it is you’re doing, you need to demonstrate that management piece of it. In the office, you need to make sure that you’re demonstrating that you’re addressing the chronic conditions and that you are managing the medications.
I would say for internists, though, one of the most important things on the hospital side is making sure that they give the discharge summary attention. A lot of people think that the discharge summary is just busy work, but the reality is, and I’m going to ask you, don’t you like reading a good discharge summary and making sure that it’s telling the story, so that you know what’s going on with your patient? Don’t you like that?
Kevin Pho: Of course.
Erica E. Remer: So I think that’s one of the pieces that’s really important on the hospital side. And on the hospital side, people never realize that the interval history was always meant to be just telling what’s going on with the patient now. I don’t know if you’ve ever read documentation where they copy and paste the entire HPI every single day during the admission. It’s not necessary. You’re supposed to be telling what’s going on with the patient now.
Kevin Pho: So I want to ask that question another way and talk about red flags. I know that you’ve mentioned several red flags already: copy and paste, making sure that your templates are updated. What are other common red flags that you see physicians do?
Erica E. Remer: One of the things, in the context of not editing your template and making sure that it’s telling what’s going on, is that you can introduce internal inconsistencies. For instance, say you’re documenting that a patient has sepsis. Of course, I forgot to mention before that the next most important thing is making sure that you are drawing your conclusions. You want to make sure that you’re taking all of your findings and everything you’re doing, and you’re going to then give a nice, specific diagnosis. If your diagnosis is, let’s say, sepsis, and in your physical exam you say the patient’s alert and oriented and in no acute distress, it sets up an internal inconsistency. That can be a red flag, especially for either a lawyer or a third-party payer saying, “Well, if the patient looked nontoxic, then why would we pay you for sepsis?” So that’s a red flag.
We already talked about the copy and paste. I think that really one of the most important things is making sure that you’re thinking about what’s going on with the patient. The tagline for my business is “putting mentation back into documentation.” I think that people have a tendency, and the reason they’re doing the copy and paste is that they think it’s saving them time. But the question is, if three days in a row you are documenting “hypokalemia, will supplement,” what you really need to be doing is not just throwing potassium at the patient. You need to be thinking, “Why does this patient keep getting hypokalemic?” and then you need to address that. So I think those are some of the most common red flags that I see people doing. I see them often.
Another red flag would be making a diagnosis that’s not supported by the documentation. On the inpatient side, the clinical documentation integrity specialist’s job is to be reading through the documentation and making sure that if there are clinical indicators that suggest a diagnosis, the doctor is making that diagnosis. And then the converse: If they make a diagnosis, do the clinical indicators support that diagnosis? Because obviously you don’t want to commit fraud, abuse, or waste, so you want to make sure that your documentation is supporting what you’re thinking and what you’re doing.
Kevin Pho: We’re talking to Erica Remer. She’s a physician and clinical documentation specialist. Her KevinMD article is titled “Fixing the broken system: improving clinical documentation in health care.” Erica, I want to talk to you about the future, and specifically AI and these generative AI tools like ChatGPT and Google Bard. It’s affected pretty much every field where the English language is being used, and it’s no exception when it comes to physicians and clinical documentation. So tell us, what do you see? Comment on the intersection between generative artificial intelligence and clinical notes going forward. What are you seeing?
Erica E. Remer: You know, I do think that there may be a role for using some sort of artificial intelligence, especially in the context of the discharge summary. But we all need to remember: garbage in, garbage out. If you’re doing bad documentation all along, and you’re copying and pasting, and you’re not putting in the detail that’s needed to be able to draw the correct conclusions, then you’re going to end up with garbage out.
I do think that the bugs they’re finding with artificial intelligence, where it’s sort of just making stuff out of thin air, I think that they’ll work those bugs out eventually. But I think that you’ve got to be careful. We’ve been using computer-assisted coding and computer-assisted CDI for years now, and I always tell people to be really careful, because you can’t just accept whatever the computer is telling you. The human being has got to read it over, because this is not busy work. To me, this is taking care of real-life patients, and if you don’t pick up errors that the computer is inserting into taking care of that patient, you can end up causing harm. To me, that’s the most important thing that we have to avoid.
One of the tools I tell people to use in the hospital for discharge summaries is to keep a running summary. Some of the electronic medical records have a place where people can keep what we used to call the handoff tool. You could have one paragraph that was kind of telling the story longitudinally, a quick summary, so that if something happened to a patient in the middle of the night, you could just read through that rather than having to read through pages and pages and pages. What I would tell them is to invest a few moments every day in keeping that updated, and then when you got to the end and you needed your narrative for your discharge summary, it was there. It existed.
So that’s the kind of thing where I think the artificial intelligence might be able to cull those pieces and parts, but what you really need to do is make sure that it’s telling the entire story. What it thinks is important and what a clinician might think is important might be two different things. I think that everybody needs to realize that you really don’t want to be just an editor; you really do want to be an author. I think that AI may have some role, but I think it should be a limited role, because we’re really trying to take care of patients.
Kevin Pho: And my final question, Erica: Tell us some of your take-home messages that you want to leave with the KevinMD audience.
Erica E. Remer: OK, well, I would like to mention that since there is nobody teaching this to anybody in the first place, I think that people should really understand that their clinical documentation integrity specialists are trying to help them tell the story. I actually created a set of modules called Dr. Remer’s Documentation Modules, where I’ve sort of parsed out the important things. I talk about general documentation, I talk about documentation in the context of quality and reimbursement, CDI, and then supporting medical necessity and medical decision making. They’re packaged at one very low price, and I think that it’s a really good tool for people to learn how to do good documentation and to recognize that their CDSs are trying to help them tell the story.
So that’s really my key. I would say that every time you’re taking care of a patient and documenting, you should spend a couple of moments thinking. OK, put your mentation back in your documentation. And then what you’re really trying to do is tell the story, but you should always make sure that you’re telling the truth.
Kevin Pho: And I’ll have a link to your documentation modules in the show notes. Erica, thank you so much for sharing your time and insight. Thanks again for being on the show.
Erica E. Remer: Thank you, Kevin. Good to be with you. Take care.
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