By Peter Basch, MD, FACP and Michael Zaroukian, MD, PhD, FACP, FHIMSS
Incorrect Assumptions Lead to Incorrect Conclusions That Misinform Policy
While Democrats and Republicans may each have their own take on how best to move our country’s physicians and hospitals from paper to electronic records, there has generally been broad consensus that widespread adoption of electronic health records (EHRs) is a necessary, if as yet imperfect, step in the evolution to better, safer and more affordable care. While there have been challenges to the logic and effects of the HITECH Act and the CMS EHR Meaningful Use Incentive Program that have catalyzed greater EHR use, stories published in in two high impact newspapers last week raised additional serious questions about the conventional wisdom that EHR use will help contain increases in health care costs.
The first, published as an op-ed piece in the Wall Street Journal, takes the position that there is no evidence from four to five decades of research that EHRs save money, and that the current policy to use financial incentives to accelerate EHR adoption is misdirected. The second, a report published in the New York Times, does not question the rationale behind the policy; instead, it presents the startling and disturbing finding that whatever policy makers were hoping for, there is evidence that doctors and hospitals with EHRs are using them to bill for more and higher complexity services – and are thus increasing costs. Worse, the New York Times article suggests that much of the higher billing may be due to widespread electronic ‘science fiction’ in which doctors electronically record findings without actually ascertaining them, while their EHR coding software actively encourages documentation resulting in unethically and even criminally inflated bills.
Our initial reactions to these two pieces were mixed. On the one hand, we were troubled by the possibility that EHRs could be directly and significantly contributing to billing fraud, a criminal activity that hurts everyone. We applauded the speed and clarity with which the US Attorney General and Health and Human Services Secretary indicated that such fraud will be vigorously pursued and prosecuted.
On the other hand, as practicing primary care physicians with longstanding informatics leadership roles and experience in our respective organizations and professional societies, we have presented and published data from our own practices showing cost savings and quality gains from EHR implementation and optimization. We have seen EHR coding decision support software from multiple vendors designed to facilitate appropriate billing rather than fraud. We have reviewed enough of the primary literature over many years of research and have deployed enough of it in our own practices to believe that well- designed, implemented and optimized EHR systems used by trained healthcare professionals in a “meaningful” way can support improvements in health care quality and value.
In light of our experiences, we wondered how a recent study could yield such strong and conclusive evidence that the WSJ editorialists could reasonably conclude that the “savings claimed by government agencies and vendors of health IT are little more than hype.” We were also curious to understand the evidence base behind the claims in the NYT report that there may be a widespread problem with EHRs encouraging doctors to document work they did not do to inflate their bills, and then using their EHR coding software to discover and document in a manner that would support fraudulent billing practices. We also were mindful about other forces unrelated to billing fraud or EHR design that drive increased physician documentation but did not see much discussion of these forces in either the WSJ or NYT stories.
The product of our reflections about these issues is a six-part blog post that can be found on the Doctors Helping Doctors Transform Healthcare web site. Below we provide a brief summary of each of the six parts and our conclusions for each, with links to each. We invite others to add their comments, questions and suggestions for moving the conversation forward to ensure that the increasingly widespread adoption of EHR systems and associated health IT results yields its intended goals of improving the quality, safety and value of health care.
In Part 1, we examine the evidence behind the claim that the “savings promised by the government and vendors of information technology are little more than hype.” We identify three major problems with the WSJ story: 1) the op-ed authors drew inaccurate and misleading conclusions from the systematic review; 2) they used conflated logic to represent several decades of research as support for their broad conclusions when only a tiny fraction (<0.1%) were relevant to the much more limited question addressed in the systematic review, all of which were completed prior to the start of the EHR Meaningful Use Incentive Program; and 3) even though the editorialists arrived at their conclusions for the wrong reason, most policy makers have recognized that health IT is at only an enabling infrastructure to the delivery of higher quality, higher value care, which is why the HITECH Act is intentionally NOT an incentive program for the mere implementation of EHRs; it is a program that incents EHR adoption of particular capabilities that are used in meaningful ways that were deemed through the process of literature review and expert opinion to enable better, safer and more efficient care.
In Part 2, we look at the recent Center for Public Integrity and Office of the Inspector General reports referenced in the NYT piece in which it was found that physicians and hospitals using EHRs show higher charges than their colleagues using paper records. Notwithstanding the legitimate concerns, anecdotal examples and significant questions regarding the prevalence and contributing factors to physician billing fraud – including features and functionalities in EHR systems – we did not find evidence from any of these reports that answer the specific question of whether use of EHR systems or their coding decision support software contributed to the billing patterns of the 1,669 (0.38%) of 442,000 physicians who had Medicare billing profiles that differed significantly from their colleagues. The OIG study also did not look at whether this small fraction of physicians billing at the highest levels were doing so inappropriately or fraudulently. We conclude that while all causes of billing fraud and abuse in any type of documentation system (paper or EHR) should be explored and reasonable steps taken to prevent and remedy them, we do not accept the premise that EHRs or their coding decision support systems promote fraud and abuse.
Part 3: Exploring the impact of EHR systems on costs and physician billing
Part 3 starts with the assumption that there actually is an association between EHR use and higher billing levels, whether or not informed by E/M coding decision support software. We explore the legitimate and even expected reasons why billing levels might increase in the short-term but also are associated with longer-term savings. We review examples of how EHRs can curb costs, why some of the gains would not be seen in the short-term, and that increases in certain costs (better access, more preventive services, greater attention to chronic disease management) would be an early indicator that EHRs were being used as more than mere documentation tools, and instead are being used to inform and support improved quality and safety. We use the example of one organization’s launch of its Million Hearts™ program which will result in higher costs in the short-term (more visits, needed testing, and some higher complexity visits) but should yield long-term savings by preventing new heart attacks and strokes that would otherwise occur.
Part 4: Is repetitive or “boiler plate” documentation suggestive of fraud?
In Part 4, we challenge the inference in the Center for Public Integrity report and NYT story that the finding of repetitive language (“boilerplate” documentation) in medical notes or similar appearing notes is prima facie evidence of documentation fraud and illegal billing behavior. We talk about the degree to which standard terminology has been encouraged in medical school and residency training since long before EHRs were used and that it is fortunate for patients that physicians are trained to use standard terms to describe and clearly communicate positive and negative findings to each other. We acknowledge that physicians can document in notes work that they did not do but that is neither unique to EHRs nor will be cured by further limiting the ability to use efficient documentation tools wisely and well. While we believe there is some role for looking at physician documentation patterns to screen for potential fraud, we write of our concerns that software that looks for documentation patterns needs to be designed carefully because much of the repetitive documentation in notes is appropriate rather than fraudulent.
Part 5: Should EHR coding decision support software be banned or further regulated?
In Part 5, we respond to the suggestion by some who were interviewed for the WSJ and NYT reports that billing fraud is best remedied by regulating and/or removing E/M coding software from EHRs and other health IT systems so they will not tempt physicians to over-document and subsequently overcharge for their visits. We provide another experience-based perspective in which the physician uses the E/M coding software to ensure use of a code that supported the current reasonable and necessary care and to ensure that the provider has not forgotten to include this documentation before signing the note.
We talk about the problems with the complex 1995 and 1997 E/M billing guidelines and why decision support is helpful to ensure compliance and designate an appropriate billing code with a high level of reliability. We share our view that as long as we retain the current payment system, E/M coding decision support will help responsible physicians ensure their compliance with E/M coding requirements without having coding be a major distraction during patient care.
Part 6: E/M documentation guidelines, “note bloat,” and a constructive path forward
In Part 6, we share our perspective that EHRs did NOT cause the documentation clutter and verbosity that is now commonly called “note bloat” but rather that the E/M documentation guidelines are the principal contributor to this problem, which is a not only a significant waste of time for the author and readers of the note, but also a barrier to more efficient use of EHRs. We argue that while EHRs make it easier to document profusely and are therefore implicated in the “note bloat” problem, EHRs are simply using their capability to assist with the documentation required for billing. We contend that documentation requirements and coding complexity contained in the 1995 and 1997 E/M Guidelines catalyzed the very conditions that the Center for Public Integrity and the New York Times reports have recently raised concerns about. We close with a summary of our observations and suggestions for moving forward.
We encourage those of you who are interested in exploring additional details or sharing your views to go to the Doctors Helping Doctors Transform Healthcare web site and let us know what you think.