Here is a so-called “complete” history for this fictitious patient, easily derived from pointing and clicking:
CC: Urinary Tract Infection
Duration: 1 week
Quality: Burning Symptoms: Abdominal Pain
Severity: 1 – 10 scale, pain is level 4.
Review of Systems:
Constitutional: Positive for Fever
Eyes: Negative for blurring
ENT: Negative for hearing problems, sinus infections, & sore throat
Cardio: Positive for varicose veins
Respiratory: Positive for cough
GI: Positive for abdominal pain
GU: Positive for UTI
Musculoskeletal: Negative for join pain
All others reviewed & negative except otherwise noted.
Lasix 20mg Twice Daily 11/12/2013
Coumadin 5mg Once Daily 11/12/2013
Family History: Cancer, Mother
Social History: Former smoker
Now, let’s look at the dictated version:
Ms. Rebecca is a 67 year old Asian female who called this morning, and asked to be seen for a UTI. She complains of a burning sensation since this past Monday. She also has lower abdominal pain. Her daughter was her caregiver, and sadly, she was killed in a car-crash over Christmas break. Her niece hired a live-in caregiver to assist her with activities of daily living.
The dictated history is more problem focused. It is far from complete. However, it’s not filled with useless information like the history in the first example. The note is personalized and reflects a conversation the Provider had with the patient.
As much as I prefer Example 2 over Example 1, as an auditor, I can no longer review the notes simply for accuracy of E/M code selection. These days, I’m looking for tobacco use, family history, allergies, immunizations, specific diagnosis codes, whether a provider prescribes name-brand or prescription drugs, whether or not the patient has any chronic illnesses, and anything else that will help the Provider survive the Merit-Based-Payment System. In addition to combing over Medicare patient files for quality initiatives, I am also becoming well-versed in the commercial insurance versions of these quality programs for all of the other patients.
Auditing for levels of service and correct diagnosis code selection, while still important, barely scratches the surface of what I review with Providers after an audit. My problem is no longer lack of documentation - it is 10 pages of templated, cut and pasted, impersonal information for each patient that may be upcoded because the EHR counts bullets and assigns codes based on the number of bullets selected. I cringe when I can count bullet points for the psychiatry, neurology, and cardiovascular portion of an exam on a patient with a urinary tract infection. The practice of cloning medical records thrives in the Electronic Health Record. Is it possible for 10 notes for 10 different patients to have the same comprehensive exam down to the “Inspection and Palpitation of Digits and Nails?”
The rebel in me cheers for joy when the Provider bucks the system and practices medicine without concern for checking boxes, and vows to focus on the patient in order to provide “real” quality-care. Yet the sensible side of me nags about Provider reimbursement, the quality of care measured by diagnosis codes, the efficiency of the practice measured by the cost per patient, and eventually my sensible side wins the argument. I find myself saying things like, “Have any of your patients sent you an electronic message yet? Have you sent any of them an electronic message? Have you been giving those tobacco handouts to your patients? I know your patients want their prescriptions hand-written, but you need to e-prescribe or you won’t pass Meaningful Use.”
Providers are not trying to game the system by clicking every button available on the template; they are trying to cover their bases with payors. I have become an auditor of code selection, quality, cost, severity of illness, and efficiency. The notes are longer, they tell me all about the patient’s tobacco use, they address the patient’s chronic illnesses in alphabetical order, and yes, every patient’s extraocular movements are intact. They are also littered with template errors and misinformation. Consequently, the US health system continues to rank last among eleven countries on measures of access, equity, quality, efficiency, and healthy lives, though the advent of the EHR promised improved quality of data, decreased costs, and efficiency.
America, it looks like we have our work cut out for us.
Rebecca Hanif, an AHIMA Approved ICD-10-CM/PCS Trainer, is with Jackson Thornton Healthcare where she assists physician practices with process improvement.