Thomson Kuhn, MA; Peter Basch, MD; Michael Barr, MD, MBA; Thomas Yackel, MD, MPH, MS,; for the Medical Informatics Committee of the American College of Physicians *
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Current Author Addresses: Mr. Kuhn: American College of Physicians, 25 Massachusetts Avenue NW, Suite 700, Washington, DC 20001.
Dr. Basch: MedStar Health, 660 Pennsylvania Avenue SE, Suite 100, Washington, DC 20003.
Dr. Barr: National Committee for Quality Assurance, 1100 13th Street NW, Suite 1000, Washington, DC 20005.
Dr. Yackel: Department of Medical Informatics, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, BICC, Portland, OR 97201.
Author Contributions: Conception and design: T. Kuhn, P. Basch, M. Barr, T. Yackel.
Analysis and interpretation of the data: T. Kuhn.
Drafting of the article: T. Kuhn, P. Basch, M. Barr.
Critical revision of the article for important intellectual content: T. Kuhn, P. Basch, M. Barr, T. Yackel.
Final approval of the article: P. Basch, T. Yackel.
Administrative, technical, or logistic support: T. Kuhn.
Collection and assembly of data: T. Kuhn.
Clinical documentation was developed to track a patient's condition and communicate the author's actions and thoughts to other members of the care team. Over time, other stakeholders have placed additional requirements on the clinical documentation process for purposes other than direct care of the patient. More recently, new information technologies, such as electronic health record (EHR) systems, have led to further changes in the clinical documentation process. Although computers and EHRs can facilitate and even improve clinical documentation, their use can also add complexities; new challenges; and, in the eyes of some, an increase in inappropriate or even fraudulent documentation. At the same time, many physicians and other health care professionals have argued that the quality of the systems being used for clinical documentation is inadequate. The Medical Informatics Committee of the American College of Physicians has undertaken this review of clinical documentation in an effort to clarify the broad range of complex and interrelated issues surrounding clinical documentation and to suggest a path forward such that care and clinical documentation in the 21st century best serve the needs of patients and families.
Observe, record, tabulate, communicate.
In the face of the confusion concerning the necessary quantity of data, the initial collection of data should be made as significant and complete as possible. The organization of the medical record should be a matter of immediate concern to practicing physicians and students. … Properly trained paramedical personnel can both contribute greatly to the data-collection phase and help teach it. The medical faculty must become far more interested and expert in teaching the analysis of medical data, the complete formulation of the problems, and the disciplined following of each.
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Brighton Medical Associates
January 23, 2015
How E&M Coding Destroyed Communications between Physicians
This position paper hits the nail squarely by citing the 1995 and 1997 E&M Coding guidelines as the primary driver of deterioration of the medical record. By requiring the inclusion of data elements that will be counted (not for content but just for their number) our medical notes have become bloated with useless data.The latest debacle is the CCD: a clinical care document, created by EMR systems for physicians meeting the requirements of meaningful use. The CCD is nothing but a compilation of all the useless data elements with no communication of useful information such as a physician's opinion or the patient's story. As a primary care internist, I am forced to look through these useless CCDs in the hope of finding a shred of communication about the patient.I don't know what the solution is, but this paper is pointing in the right direction. The 1997 E&M coding guideline needs to be re-engineered and the CCD needs to be retooled to make it more clinician friendly.
David L. Keller, MD
Congress gave health insurers the right to violate patient privacy - this must end
Physicians insert “boilerplate text", defined as words which convey no meaningful medical information or insights, into their clinical notes mainly to satisfy documentation requirements imposed by the Medicare Evaluation and Management (E&M) Services Guide. Medicare and nearly all private health insurers adhere to the E&M Guide to determine their payments to physicians. These E&M service definitions largely dictate the format and content of physicians’ progress notes.There is a natural tension between physicians, who want to be paid in full for their efforts, and payers, who want to minimize payments to physicians. Payers enforce physician adherence to E&M documentation and billing regulations by hiring clerical employees called “coders” to audit patients’ clinical charts for documentation deficiencies. To avoid fines and prosecution, physician notes are usually generated first and foremost to fulfill the requirements of these coder audits, rather than the needs of their fellow clinicians.Coders determine whether a progress note meets the billing requirements mainly by checking how many elements of defined data are present. Most physicians are not completely familiar with the complex, confusing, and arcane E&M requirements, so they load up their notes with as much computer-generated boilerplate as they can, hoping it will include an overlooked element of data needed to satisfy a coder’s audit.This whole system must be discarded, or there can never be any hope of having progress notes that communicate clearly and concisely between clinicians. A quick and sure way to end this “tyranny of the coders” is for Congress to terminate the exemption granted to payers by the patient privacy laws, including HIPAA. This would eliminate inspection of the clinical chart by payers and their coders. Payers would no longer need battalions of coders, who could be relieved of their duties and retrained to perform more productive tasks.Payers should not be allowed to read, inspect, or audit patients’ clinical charts; this is a violation of patients’ medical privacy. It harms patients by causing physicians to spend more of their limited time generating progress notes, leaving less time for interacting with patients. Payers must verify physician billings in some way which does not violate the privacy of patient charts. Payments could be determined by the average amount of physician time required to treat the patient’s illnesses and manage their chronic conditions, as determined from the submitted diagnosis codes. Physicians could submit attestations for any required variations. In a world without E&M coding requirements, the clarity and efficiency of clinical documentation could be improved enormously, with more time for physicians to actually examine and treat patients.
Jordan B Glaser MD, Dina Wong, Albert Villarin MD
Staten Island University Hospital, New York
March 8, 2015
Clinical Documentation in the 21st Century: Executive Summary of a Policy Position Paper From the ACP
TO THE EDITOR: The Position Paper appropriately prioritizes the need for the electronic health record (EHR) to focus on the documentation and enhancement of direct patient care. The authors felt that features of this goal are unlikely to be optimized as long as the record’s format and content is primarily based on coding and other regularly requirements.
These requirements include meaningful use (most providers have failed the onerous requirements for EHR infrastructure incentive payments under the second round), the Center for Medicare and Medicaid Services outpatient Physician Quality Reporting System Measure-Applicability Validation Process (my infectious diseases practice is currently appealing ~1% reimbursement cuts for physicians who don’t even see outpatients), documentation and coding requirements for inpatients (which not only affects hospital reimbursement, but also acceptable lengths of stay and mortality rates for hospital monitoring purposes), and hospital reimbursement penalties under Value Based Purchasing (VBP), Hospital Acquired Conditions (HAC) and the Hospital Readmissions Reduction Program (HRRP).
One solution to the regulatory problem may be through electronic data extraction methodologies that go beyond the myriad of check off boxes and “copy and pastes” within the record. Our health system is about to implement one of these electronic systems. There are many examples of how the system will function. It can cull the electronic record daily to identify patients who no longer have indications for a Foley Catheter and thus decrease Catheter Associated Urinary Tract Infections under both the VBP and HAC programs. The system will cull radiologic studies and electronic physician notes for “pleural effusion” in cases of iatrogenic pneumothorax. Diagnosis code 5119 (pleural effusion NOS) excludes Patient Safety Indicators (PSI 06) related penalties for iatrogenic pneumothorax under both the VBP and HAC programs. A template will be used to assist the system to cull data to identify congestive heart failure patients appropriate for hospice care. The latter will not only assist in patient care but will also diminish 30 Day Mortality Rate penalties within VBP. The electronic data extraction system will also be used to optimize documentation and coding as our institution switches from ICD-9 to ICD-10. However, the real goal of these methodologies will be to allow the physician to concentrate on the true purpose of the EHR, to richly tell the story, enhance critical thinking and assure communication among providers, patients and families.
Kuhn T, Basch P, Barr M, Yackel T, for the Medical Informatics Committee of the American College of Physicians. Clinical Documentation in the 21st Century: Executive Summary of a Policy Position Paper From the American College of Physicians. Ann Intern Med. ;162:301–303. doi: 10.7326/M14-2128
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Published: Ann Intern Med. 2015;162(4):301-303.
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