Smart Moves for Smarter EHRs

In a couple of recent articles that are not connected, there is an underlying connection.  One, in "For the Record" discusses The Hazards of Note Bloat and the unintended consequences of having a lot of information that doesn't truly say much about the complexity of the patient's condition, not to mention that it is "difficult to view, notes lengthen and errors accumulate."  But wait, aren't EHRs supposed to reduce errors?  The article goes on to explain how narrative (dictation/transcription) notes have been reduced, but not completely eliminated.  It also discusses speech recognition and its implementation this month. 

The next article talks about the value of outsourcing as a cost-savings process to reduce costs and how this is happening in a big way in Canada.  This model has been shown again and again to be cost effective and many hospitals across the US have already embraced this practice to help reduce costs.

In yet another article, 3 major healthcare groups were identified as having caught the financial flu and are not doing particularly well at this time. 

In reviewing the 3 unrelated articles, it became apparent that there may be a myopic view of how to balance reducing costs with optimal EHR utilization.  Consider this.  EHRs are here to stay.  We need them and the value they bring to healthcare overall.  What we don't need is documentation that doesn't improve the quality of the patient encounter.  We need streamlined, content-rich, not bloated notes that drone on endlessly with what the previous note stated.  We need to optimally enable physicians so they have the time to see a growing patient population, not spend endless hours doing their own data entry.  We also must get the level of detailed specificity now that will be needed as the ICD-10 date edges ever closer.  Healthcare organizations must be fiscally healthy enough to provide care and continue to be viable as baby boomers get to Medicare age.  So yes, they do absolutely need to cut costs in the right places but keep those that enhance their revenue capabilities. 

Here's the conundrum in summary.  If healthcare organizations and hospitals focus only on reducing costs at the expense of eliminating medical transcription/editing, they are using a tunnel vision approach that will reduce costs but will simultaneously fail to optimize reimbursement.  Complete, detailed documention renders optimal coding, which leads to appropriate and optimal reimbursement.  If this process becomes muddy through "note bloat" or abbreviated input from extremely busy clinicians, the revenue cycle process may breakdown and the endless cycle of trying to reduce costs and not optimize documentation will continue. 

Stop the broken cycle of cost-cutting measures as the only option.  It's time to see the bigger opportunity and realize the value gained in the outsourced model of quality dictation/transcription and speech editing process to capture all the details needed for ICD-10 today.  This can get healthcare organizations over the financial flu and on the road to recovery. By adopting a practice of excellent documentation practices, these 3 unrelated items can become related in a way for long-term success with the EHR and improve patient outcomes as one of the most important goals.          

Challenges in 2011

As we start a brand new year, it is going to be particularly important to take notice of all that is happening in healthcare documentation. The sense of urgency for hospitals and providers to adopt EHR technology is on the rise and shows no signs of slowing down, despite the challenges, expenses and the myriad of complexities also known as meaningful use.

So what is an MT to do? Do we just go through our normal day and hope that our job is not the one eliminated? Or should we look at credentials, education and find new roles that we can do? Personally, I think it is a mistake if we don't get active in taking a long, hard look at this head-on instead of hoping that we can ride the wave to the shore.

We have heard for years that medical transcription and coding are similar (from the standpoint of clinical knowledge) and yet they remain, for the most part, very separate processes. It seems prudent to revisit these 2 tasks and see how we might bring them closer together in an effort to gain efficiencies and speed up the billing process. Having worked as both a coder and a transcriptionist, I know the skill sets are very similar. We must know and understand the language of medicine, A&P, pharmacology, disease process and so much more.

Even aside from the obvious coding option, there are others that come to mind. For those who aren't necessarily resigned by geographics or other requirements to working at home, becoming a scribe may be an option. There are probably individuals working as scribes who will tell you it isn't the same job and I completely acknowledge that it's not the same, however, it still comes back to all the medical knowledge and then training to perform the tasks that the physician needs for entry into the EHR. It can be learned, and you clearly have a huge head start.

Then what about analytics, quality reporting and a host of other tasks that we can learn? There are many options, and AHDI is exploring these with several current initiatives, but there is one step first. We need to understand that much of what will take place when the nation's healthcare goes electronic hasn't quite yet been fully determined. The roles are still being discovered. So the potential is there -- and it won't come without additional training, possible college preparation and credentials. This is just simply a call to keep eyes and possibilities wide open.

What can you do today? Start learning all you can about these new systems and keep your networks strong. Be informed and don't be afraid to consider going back to school. At a time when I thought I wouldn't need to go back to school, I find myself today enrolled at the University of Cincinnati in their BS HIM program to convert my RHIT to RHIA. Funny thing is that I looked into this program back in 2006 and decided not to do it, because I didn't think I needed to. Of course the enrollment advisor reminded me that had I done it then, I would already have gradutated. I guess the moral of this story is never say never - you might be surprised by the necessities in an evolving career!

EHR Process: Speak Your Preference

EHRs and meaningful use (MU) are getting so much publicity. There is the carrot (financial incentive) and stick (reduced reimbursement) approach to get them in place by 2014 with the promise of reducing costs, improving patient outcomes and patient safety. Through all of this publicity, seems we haven't heard enough from the chief care giver - the physician.

Many of the EHRs that have been approved by CCHIT don't include a dictation/transcription option. CCHIT may not ultimately be the approval body. Interestingly enough, MU definitions haven't been finalized. So there are goals to meet that haven't been fully defined and timelines that associations like the AMA and AHA along with a host of other national groups that have spoken clearly about how the all or nothing MU criteria plan is ill-advised. They agree that the timeline is not realistic.

We probably all can agree that EHR implementation without meaningful use doesn't get us to the goals promised. And we understand that it is a given to migrate away from paper records. However, the rush to get it done seems to put physicians and a practical improved approach to healthcare delivery in the system that we have, in the backseat.

Let's look at this from an objective perspective. Now we have healthcare reform. That's great news for so many who don't have healthcare today. It means that an additional 32 million (estimated) Americans will have access to healthcare who previously did not or did if their conditions became critical enough for them to present to the ER. What will healthcare reform do to physician case loads? To hospital census? Let us not forget that we have an aging population with baby-boomers approaching retirement. Do we have enough physicians for all this increased volume?

Now let's look at how many EHR systems approach healthcare documentation. They are designed for the physician to become the data entry clerk - and in truth, many are operating this way today. VA's VISTA system, Kaiser Permanente, and there are a host of EHRs designed for ambulatory settings and physician office practice that utilize the same approach.

Here's a thought. Do you see the president of a bank entering deposits and counting out cash at his bank? No, so why would we ask our most highly educated member of the healthcare delivery team to become a data entry clerk?

Currently 1.2 billion patient reports are created by expert medical transcriptionists who have trained and many have become credentialed in their field. Narrative dictation captures the unique circumstances of each individual patient. No two patients are alike in their history and even presenting symptoms. And to leave out important details of the patient's additional illnesses can most certainly impact hospital and physician revenue. So why would we A. slow physicians down entering the detail and B. risk lower reimbursements?

The purpose of this blog post is just simply this. Consider: The physicians who are mostly going to be time and resource-impacted by EHR implementation need to speak out in favor of the ability to continue to document patient encounters in the most efficient and complete way. Physicians' voices must be heard in this evolution to electronic records. What EHR systems must do is provide an avenue for physician choice in documentation practices.

If physicians want to self-enter - then that should be an option. However, for those physicians with a patient case-mix that is complex and those with multiple medical problems, their option to continue to dictate will mean the difference in their ability to increase the demand on their time as patient loads increase.

Physicians - please speak up - be sure that you have options in how you document patient encounters. You are the CEO of the healthcare delivery team and the process needs to provide better patient safety and ensure that your time is optimized while ensuring appropriate reimbursements for all you do.