A few weeks ago I saw a patient Friday afternoon after 5 pm. It was unscheduled and unexpected (someone scheduled for someone else who was running very late), and it was a simple acute problem, so I was asked if I would handle it.

Of course, my exam rooms were already turned down for the day (no lights, computers off). I decided to take the patient back, put paper on the table, turn the computer on, get the vitals, etc. Because it was a simple problem and the patient was a good historian, I decided to see if I could finish my visit before the computer fully booted up (we are a health system with multiple layers of security, so PC boot up from fully off to fully connected takes several minutes). And yes, I finished my visit and wrote a paper prescription for an antibiotic before the computer came up.

It was 100 percent eye contact, no paper, no PC, all face time–a very pleasurable experience for me and the patient. The patient could tell me no drug allergies, so the antibiotic I used (clarithromycin) wouldn’t hurt him. However, there were several things not so good about this 100 percent eye contact / 0 percent EHR visit.

One of the rarely discussed implications of EHR-enabled care (particularly true for providers in informational fields; less so for proceduralists) is one is not really asking for the same care as what we used to document on paper records. We are expecting the doctor to address the complaint that brought the patient in AND missing care opportunities. After the computer came up I saw that:

1. Patient was two years overdue for a colonoscopy.
2. We had no documented preventive gynecology care. Again, this was not my patient, and it was not clear whether the patient was seeing a gyn outside of MedStar, or the PCP had just forgotten to address this over the past few years.
3. We are doing Million Hearts at MedStar and this patient should have been advised to be on low-dose ASA but this didn’t happen.
4. The last labs showed an elevated sugar and the next visit was supposed to include an A1C test.
5. The patient was a smoker and had agreed to try patches and was to report back at her next visit on whether the patches helped.
6. The patient was also on a statin, so I shouldn’t have given clarithromycin.

What I am describing above is an example of moving beyond existential care (reacting solely to what the patient presented with) to a “shared agenda” visit – where BOTH the patient’s issues and missing care opportunities are prioritized and addressed (as time permits). Some of my colleagues have suggested that what I mention above would spell the end of volume and access, as every patient visit would now need an hour or more. For some exceedingly complex patients that may be true, but I would suggest that these exceptions are managed as we do now; doing what is most pressing first, and then having the patient return for the rest. That said, the story above is more typical of my patient visits.

The care opportunities described first appear to us (patient and me) as a global – so we could select all or a few. For example, our lab was already closed but with a few clicks I could have created the lab order or just informed the patient that she was overdue for a visit and labs (and flagged my partner who needed to do chronic care follow up).

1. Patient was two years overdue for a colonoscopy–“It appears that you are overdue for a colonoscopy – shall I order one today?” One click.
2. We had no documented preventive gynecological care–“Are you regularly seeing a GYN for pelvic exams and paps?” If yes, single click; if no, patient advised to schedule with her PCP here.
3. This patient should have been advised to be on low-dose ASA–“This has nothing to do with your visit today, but as you know, we are trying to identify people at higher risk for heart disease, and you would benefit from low dose-aspirin. Are you already taking it?” Again, depending on answer – which can also be a decline–single click and done.
4. The last labs showed an elevated sugar and the next visit was supposed to include an A1C test–As above, I could have created the lab order for the patient, and the patient would return at her convenience to get it done.
5. The patient was a smoker and had agreed to try patches and was to report back at their next visit on whether the patches helped. “Did you use the patches? Did they help?” I could at least get that. I probably would not have gone the next step if they didn’t help–as each of the docs in our practice does something a bit different–but at least I would have raised the issue. Also, it would have been pertinent to raise during a visit for a respiratory infection–as patients who smoke who get recurrent infections may be more amenable to suggestions to quit.
6. The patient was also on a statin, so I shouldn’t have given the clarithromycin, and I didn’t do a med review BEFORE prescribing the antibiotic, and I didn’t give the patient a clinical visit summary. I would have, of course, received the alert in real-time and backed off the clarithromycin and prescribed something else which would take a few seconds.

For me, it would have honestly taken an additional 1.5 – 2 minutes, and certainly would have caused me to read and think and explain more than I did. From a billing perspective, this evolution from a quick “fix this problem visit” to a “fix this problem and help take care of the entirety of me” visit may have justified an increase in billing level (perhaps from a level 2 to a level 3 visit). The financial impact to the payer would have been a slightly higher bill for this “max packed” visit – but it would be less than having these all occur separately. The financial impact to the patient would be to save money – as they would have one visit and one co-pay, instead of multiple visits and multiple co-pays (not to mention taking time off from work to see me).

Depending on one’s specialty, optimization of care, utilizing the infrastructure of the EHR changes the doctor-patient contract. As my patients have come to expect, they come in with their list and they know I will have mine. Patients may be offended if I were to be rude (I hope this has never happened) and ignore their issues for the sake of my issues. However, I have found when both sets of issues are respectfully addressed, it is appreciated by patients. I have been told more than once, “Doc, I know you are on top of things when it comes to my health; thank you.

”E&M coding is outdated and primarily relates to documentation of acute care and not what I am referring to above. That said, by creating apparent safe harbors from billing fraud with over-documentation, it has served as an impediment to optimization of EHR-enabled care–in particular the type of care I described above.

EHRs need to improve and be made more usable and useful towards the overall mission of making care better, safer and more value-laden. How we optimize them within the evolving healthcare ecosystem will ultimately determine their value. Our shared goal should be to make the time “in front of the screen” of the highest value for doctor and patient; and not to consider screen time as something to avoid.

This blog was first posted on Clinical Innovations and Technology on May 6, 2013
http://www.clinical-innovation.com/topics/ehr-emr/perspective-its-not-either-or-patients-and-ehrs

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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.    

Part 1: Critique of the Wall Street Journal op-ed piece

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. 

Part 2: Critique of the New York Times story

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.

By Michael Zaroukian, MD, PhD, FACP, FHIMSS and Peter Basch, MD, FACP

Incorrect Assumptions Lead to Incorrect Conclusions That Misinform Policy

Please refer to Part 1 of this post for our comments on the recent Wall Street Journal op-ed questioning the policy behind the EHR incentive program; Part 2 for our comments on the extent to which EHR use was associated with higher short term charges, as published in the Center for Public Integrity report and recently summarized in the New York Times; Part 3 for our comments on where one would expect EHR use to show short-term cost increases;  Part 4 for our comments on repetitive or boilerplate verbiage; and Part 5 for our comments on billing coding software.

EHRs did NOT cause note-bloat (clutter and verbosity).  When we started training, only medical notes of 3^rd year medical students consisted of multiple pages of statements of negation, such as “patient denies shortness of breath at rest, patient denies shortness of breath with exertion, patient denies shortness of breath when lying down, etc.”  Even then, this repetitive and burdensome training requirement felt more like a grade school punishment (stay after class and write on the blackboard 50 times, I WILL NOT CHEW GUM IN CLASS); it served its purpose of making new students remember the exact verbiage and when to ask each question on the next ‘Review of Systems’ item on the list.   Thankfully, the nightmare of having to produce or read such verbose monstrosities stopped with a student’s advancement to the 4^th year of medical school.  Medical training thereafter included coaching on how to concisely document only what was important (e.g., the most pertinent positives and negatives to establishing a diagnosis or planning treatment), with the understanding that based on your training and expertise, you would best use your time in making better decisions rather than wasting it in superfluous documentation; likewise, you would show respect for or other providers’ time by producing for them concise and informative notes.  In fact, you could pretty much tell someone’s level of training and clinical maturity by their consistent ability to achieve the triple crown of completeness, clarity and conciseness in their clinical notes.

All of that changed abruptly and durably in 1995; this was not due to the introduction of EHRs but rather was a side effect of an effort to solve what was seen as a provider billing “fairness” problem.  Prior to 1995, providers were largely free to self-declare whether a visit was “limited, intermediate, or comprehensive” – and document as appropriate.  The provider’s bill was an attestation of the level of service, and the documentation of that service (still primarily using standardized boilerplate verbiage) was left to the provider. This new approach, known as the Evaluation and Management Documentation Rules (E/M Guidelines) clarified that the level of service and thus the basis of the bill was NOT what was done, but rather was what was documented if the element of care was also medically necessary.  The guideline explained the documentation requirements in a series of complicated tables specifying how many of which elements of history, examination and medical decision-making were required to support each level of service and how they differed for new patients vs. established patients, as well as for patients receiving primary care vs. specialty care.

While the specifications were described in detail, they were not clear and unambiguous to many providers and could not be easily done in one’s head, or even with coding sheets.    It can be confusing and difficult for providers to correctly code a visit by counting the elements in a paper note or from the printed output of an EHR note; different providers might code the same note differently.   The proliferation of entire new industries of coding software, coding consultants, and coding auditors that followed the introduction of the E&M coding guidelines is further evidence of this complexity and confusion. 

In addition to creating ongoing provider confusion as to what exactly is needed to bill for a particular service, the 1995 and 1997 E/M Guidelines catalyzed the very conditions that the Center for Public Integrity is now concerned about.  The coding rule complexity, along with major penalties for over-coding increased the probability in the paper chart world that providers would deliberately under-code their visits to minimize the financial and reputational risks of being caught in the ‘speed trap’ of inadvertent over-coding.  With the complex math required to tally and correctly code visits using what was then the new E/M guidelines, it is no wonder that EHR vendors began to use the arithmetic capacity of their EHR systems to develop structured data entry strategies that could capture and count the elements of care that could inform more accurate E/M coding.  Eliminating under-coding and facilitating appropriate coding became an important aspect of the business case for physicians purchasing an EHR system. 

Along with the confusion and wasted time and effort mentioned above, the E/M guidelines struck a death blow to brief and cogent notes.  It actually takes much more time to think through everything that should be considered and then create a concise, 250-word visit note from what would otherwise be an undisciplined 1000 word stream of consciousness that regurgitates superfluous or irrelevant data along with the key findings of a clinical encounter.  However, the E/M guidelines now represented an actual financial penalty for the brevity that contributed to conciseness and clarity.  Where what you document according to arcane rules now becomes more important than what you actually do during a visit; it is no surprise that not only do we have providers who complain that they feel like they spend more time and energy creating  documentation than caring for the patient, we also have a payment environment that encourages ‘verbosity PLUS’ – with the downside of insufficiently documenting a service being not just that a bill will be rejected but the added specter of accusations of “billing fraud.” 

It gets worse.  The E/M documentation guidelines do indeed predispose some doctors to over-document (which depending on the patient and provider, could include findings that may not have actually been procured), driven by the fear of failing a coding audit.  The guidelines are clear that since documentation is the ultimate defender of one’s billing practices, one should make sure that the documentation supports the billing level.  By the way, CMS officials also made it clear that they consider under-coding to be billing fraud, even if it is never prosecuted.  

Yes, it is true that EHRs make it easier to populate notes with templated text or previous findings, or even many such findings, with a single click.  However, the reason why physicians feel anything but embarrassment about having their electronic signatures affixed to bloated and inelegant notes is not the fault of the EHR, and certainly not the fault of the EHR incentive program, it is because of payment policy.  In this case, the payment policy is not just rewarding volume; it is rewarding verbosity using standard terms that expands the volume documented (even if one stays within the bounds of medical necessity).

To the point of EHRs enabling over-coding and increasing healthcare costs – when the provider payment system requires that a certain number of fields be completed to justify payment; there is valid cause for fear in the provider community that they are all likely to be suspected of “billing fraud.”  There is enough ‘wiggle room’ in the documentation rules that providers may never really know if a given note meets a particular coding level. As a result, there is a constant pressure to more extensively document one’s findings (over-document) and err on the side of under-coding. 

Now take this monster spawned from the perverse payment system – the bloated and inelegant medical note – and run it through an EHR.  As most EHRs now have coding software that analyzes structured notes and indicates the billing level that fits the documentation, providers now have a real-time, high-reliability coding expert (coding software) that can correctly suggest the correct code supported by their current documentation, for example, a level 4 visit rather than the level 3 that their intuition and greater fear of overestimating the correct code would have caused them to code previously.  The provider might have been over-documenting and/or under-billing for years but  now, armed with this real-time coding advice, they can confidently and systematically “right-code” each visit.  

Our conclusions:

(1)    True billing fraud is a crime that hurts us all.  We support the call by Attorney General Holder and Secretary Sebelius for vigorous prosecution of fraudulent billing.  While our defective payment system might seemingly allow for verbose notes to facilitate higher billing, billing guidelines also reference appropriateness and medical necessity.  We thus remind our colleagues that over-documentation of what was not performed or what was clearly not necessary is unethical and unprofessional, particularly when it is done with the intent to inflate a bill.

(2)    We believe the Wall Street Journal op-ed misrepresented the conclusions of the recent report from McMaster University investigators on the economic analysis of EHRs used for medication management.  We agree that too few reliable studies have been conducted; and even fewer that present an end-to-end analysis of modern EHR systems with embedded value-based decision support, used in care settings where the business driver was not solely volume and complexity of services.  We do not believe that the McMaster study says anything negative about existing policy regarding incentives for EHRs and the Meaningful Use program.

(3)    The report by the Center for Public Integrity presents troubling findings about a very small number of physicians with aberrant billing profiles; as well as presenting inferences and comments about EHRs, documentation, and fraud; and presents conclusions based on conflated logic; and not the conclusions of the OIG.  We strongly support the call from Attorney General Holder and Secretary Sebelius to seek out and prosecute intentional and criminal billing fraud.  That said, even the OIG report did not suggest that the small number of physicians found with aberrant billing profiles committed billing fraud.

(4)    Even if a report suggested a clear association with EHR use and short term cost increases (and these recent reports did NOT); that is not necessarily an indication of a problem.  In fact, the underpinning of the value of decision support for many fields, primary care in particular, is to redress the fact that necessary and appropriate preventive and chronic care services are severely underperformed in the US.  Any such study would need to look at where these excess costs occurred, and if the excess costs were actually a reflection of EHRs doing their job in improving processes of care, thus leading to long-term cost savings from disease prevention, early detection and better chronic disease management.

(5)    Repetitive and/or boilerplate documentation across patients and for the same patient over time is not prima facie evidence of inappropriate documentation; it is prima facie evidence that the person authoring the note graduated medical school. Repetitive and/or boilerplate documentation was not created by EHRs; it is present in handwritten and dictated notes, and is typically the source of drop-down list choices for EHRs, based on specialty and scope of practice.  Physicians should not be threatened for consistent use of terminology just because common findings are indeed commonly found and documented in a consistent manner.

(6)    Coding software is the electronic expression of open and transparent coding rules. These coding rules are complex, and because physicians are paid for documentation of the complexity of medically necessary services and not for an attestation of such services, physicians may be down-coded, not paid, and subject to billing fraud audits and penalties, for forgetting to document even a single element of a multi-page document.  We acknowledge and are troubled that there are individuals who misuse a tool that helps others comply with complex regulations in a professionally appropriate manner.  However, we do not believe it appropriate to penalize those who would use the software wisely and well to prevent those who would misuse it from doing so.  Those who seek to deceive and defraud will simply find another way.

(7)    The existing Evaluation and Management (E/M) billing guidelines of 1995 and 1997 have not served their intended purpose, which was to make medical evaluation and management service billing transparent and fairer.  Instead, the guidelines have created confusion that continues to this day, and makes many doctors feel like they spend more time documenting or worrying about what they document.  Note-bloat is wasteful of the documenter’s time and it often distracts providers from using the EHR for what it was intended – to make care better, safer, and more affordable.  It also creates verbose monstrosities for the next provider of care, where the ideal of a concise clear note appears instead as a text-based “Where’s Waldo” puzzle in which important information needed to ensure quality care is hidden from view.  It has also necessitated an entire industry – coders, coding instructors, coding auditors, and coding software.  We contend that a different payment system that does not rely on rules that encourages “note-bloat” and with specifications that only professional coders can understand, would free up time and resources that could be better devoted to direct patient care. Evolving from our current payment system to one that pays for appropriate services and outcomes and NOT bloated documentation will help to reduce the burden on the producer and reader of medical documentation, and should reduce cost in the system by allowing practices and hospitals to spend more of their time and efforts on care, rather than documentation and coding.  It should also reduce concerns of EHR use as a cause of billing fraud.

(8)    We do not need any more research that concludes the obvious, that ‘EHRs in and of themselves do not make care better, safer or less costly.’  We and most others already accept this, and current EHR incentive program policies reflect a similar conclusion through their incenting of meaningful use rather than EHR implementation and adoption alone.   Studies of health IT effectiveness should look at system goals and the inherent financial incentives for performing or avoiding the performance of specific services. In that context, we should then examine whether health IT has an effect on adherence to goals, costs to achieve these goals, and other objectives.  It is foolish to study health IT infrastructure divorced from how it is deployed and used.

(9)    The Meaningful Use incentive program is far from perfect; we are regular commentators for proposed rule enhancements and have no shortage of opinions as to what could be improved.    However, on balance we believe that the Meaningful Use program is a reasoned one that has succeeded in accelerating movement of the health IT industry in a positive direction, and moving providers toward use of steadily improving health IT that will make care better, safer, and less costly. 

Tell us what you think – please add your comments and suggestions to this discussion.

By Peter Basch, MD, FACP and Michael Zaroukian, MD, PhD, FACP, FHIMSS

Incorrect Assumptions Lead to Incorrect Conclusions That Misinform Policy

Please refer to Part 1 of this post for our comments on the recent Wall Street Journal op-ed questioning the policy behind the EHR incentive program; Part 2 for our comments on the extent to which EHR use was associated with higher short term charges, as published in the Center for Public Integrity report and recently summarized in the New York Times; Part 3 for our comments on where one would expect EHR use to show short-term cost increases; and Part 4 for our comments on repetitive or boilerplate verbiage.

Some have suggested (and some rather vehemently) that whatever the cause of billing fraud, it is best remedied by regulating and/or removing all coding software from the hands of all physicians.  The rationale behind this demand is that whether or not physicians intend to misuse existing coding decision support tools, there is simply too much temptation to expect them to behave ethically and resist the urge to pad notes and inflate billing codes by documenting findings that were never elicited or actions that were not actually taken. Little if any mention is made of the possibility that the physician is simply using the coding software to ensure she uses a code that is supported by current documentation or to provide a reminder to the provider before signing the note that findings or actions that were done and medically necessary (e.g., focused physical examination findings or elements of the Review of Systems) have not yet been documented, whether due to interruptions, distractions or competing priorities during the visit.  

While it may seem reasonable to some to remove or severely restrict the functional capacity of coding decision support software, we contend that doing so is not warranted simply because it is possible to use the decision support for fraudulent purposes.  As physicians who have been in practice continuously since the release of the 1995 and 1997 Evaluation and Management (E/M) billing guidelines, the casual observer might expect that we would know them cold, and thus have no need for guidance.  For those who have never actually seen these guidelines, while straightforward in principle, in practice they are exceedingly complex, and for paper notes it typically requires a professional coder to manually review a note and determine the appropriate billing level with a high level of reliability.  This is reason enough to suspect that there is a huge problem with the guidelines.  Doctors are trained and trusted to make life and death decisions on a daily basis, but not to understand the level of service they provide to a patient.

The truth is that doctors do have a feel for the level of service they provide, based on how many problems are addressed during a visit, the amount of history gathering necessary to make appropriate decisions, the amount and depth of physical examination necessary, the amount and type of information that needs to be reviewed, the number of tests that need to be performed or ordered, and the amount and complexity of medical decision-making required. Under certain circumstances that are uncommon for primary care physicians, all of these elements may be ignored, with the billing level determined strictly by time, assuming that the documentation of time spent and topics covered in patient counseling or care coordination is sufficiently documented.  However, when time-based billing criteria are not met, accurate billing code determination requires counting and categorizing specific elements of history, physical examination and medical decision-making using sufficiently complex specifications and combinations that it is very difficult for many physicians to manually determine the appropriate E/M code from a note rapidly and accurately.  This is true whether the note is generated on paper or created in an EHR. 

Prior to EHRs and even now, many doctors must turn to laminated cards,  pocket guides or desktop documents to remind them of the documentation elements required to satisfy a particular E/M level of service.  One of us is required as part of his large group practice to review a number of office visit EHR notes of practice colleagues every six months and audit them for E/M coding accuracy.  The process of auditing the notes requires counting and organizing the elements to determine if the E/M service is justified. It is a dreaded task that if done carefully is painstakingly slow, requiring one’s undivided attention and concurrent use of a coding guide to minimize the chances of manual error. Accurate coding is not an activity that lends itself to multi-tasking and interruption, but it is precisely what most doctors must contend with regularly in their offices or in the hospital.  

That fact alone is reason to conclude that something is terribly wrong with the E/M system, and thus it bears restating.  The essence of medical practice is providing thoughtful advice and care to the very best of our abilities; and more often than not in severely time-limited settings which are further infused with seemingly continuous distractions and interruptions.  Yet having no choice if we want to get paid for our work, we tolerate a coding system that further adds to our thinking load and distracts our time and attention from patients during and after encounters.   

There are several, mostly reactive responses physicians take to manage the stress of this dysfunctional coding system:

1. Always use “safe” codes (ones that fit the billing mean for your specialty, or even one code below), and thus remove E/M coding rules from the list of distractions during care.  Consciously or not, this is what some doctors routinely do, underpaying them for their work and exposing them to accusations of technical billing fraud. Overdoing and over-documenting (to stay within the boundaries of “safe” codes) wastes provider and patient time that could be used for more important purposes, while under-billing deprives the provider of resources that could be used to improve patient care services.
2. Mostly use “safe” codes but keep an E/M coding guide document or laminated card available and use it occasionally to submit a higher billing code when a quick review of the guidelines gives the provider sufficient confidence to do so. Although we do not have systematic data, we contend that these two coding approaches remain extremely common in care settings lacking coding decision support.  The OIG report focused on the 0.38% of doctors who almost always use the two highest billing codes.  They did not report on what we believe might be the typical practice for many if not most individual physicians – they bill the great majority of their services at the same billing code (for example, >70% of E/M codes are level 3).
3. Retire the E/M billing guidelines.  We believe they have not served their intended purpose of making coding fairer.  They distract attention away from direct patient care and thus decrease the effectiveness, efficiency and perhaps even safety of care.  They divert money away from actual care by necessitating expansion of the coding industry.  Sounds crazy?  That actually was the nearly unanimous conclusion in 2002 of the HHS Advisory Committee on Regulatory Reform.  Section 941 of the Medicare Modernization Act of 2003 required the Secretary of HHS to conduct a series of pilots of alternative payment systems with the idea that one or more would emerge to replace E/M coding.  However, these pilots were never conducted.

As long as we retain the current payment system, there unfortunately remains the need for a fourth option – use coding decision support to better ensure compliance with E/M coding requirements without having coding be a major distraction during patient care.  This approach, as distasteful as we find it to be, reflects the view that coding accurately is as important as safe prescribing.  Safe prescribing (which needs to be done every day in settings of continuous distractions) requires some level of decision support, which is why the EHR Meaningful Use incentive program requires activating drug-drug and drug-allergy alerts. “Safe” coding that is highly accurate, efficient and mitigates risk of inadvertent over- or under-coding for E/M services requires computerized coding decision support and can be integrated into EHR-supported clinical workflows), yet some have called for removing coding decision support from EHRs.

Current Medicare regulations allow such coding software to exist, but appropriately restrict its function to ‘advice only’, rather than to independently determine and automatically record the level of service and associated E/M code.  This ‘advice only’ restriction is important because EHR systems can at best determine the required elements of documentation, but not the elements of appropriate documentation.  One of us (MZ) routinely uses his EHR’s E/M coding advisor software, but only after first completing the documentation felt to be necessary and appropriate.  The coding decision support is then used to confirm that the billing level is never higher than that supported by the advisor and his judgment of medical necessity (which no advisor can assist with today). Occasionally a lower code will be selected than supported by the E/M advisor because medical necessity was felt to be lower than what the documentation itself supported.

Whether used regularly or occasionally, we have both found the coding advice helpful; the majority of the time the advisor agrees with the E/M code we intend to use.  Occasionally it indicates that the documentation unexpectedly supports a much lower than expected code based on the work we did.  In those circumstances, we have found the E/M advisor rapidly points out required by missing documentation fields (such as a structured chief complaint) – something that was obviously obtained, but not documented in the right field.  We can then go back and complete the missing documentation regarding the care that was provided and medically necessary.  We believe this is how most physicians use coding advisors (whether embedded in EHRs or otherwise).  That said, for the small fraction of providers who intend to commit fraud, coding decision support can make it easier for them to do so.

Just like the OIG did not investigate whether any of the 0.38% of providers using the highest two billing codes at least 95% of the time committed billing fraud, it is also unclear that no billing fraud exists among the remaining 99.62% of providers.  However, we believe that the vast majority of providers are not attempting to bill Medicare for higher levels of E/M services than were actually delivered to patients, and that they attempt only to bill for services that are reasonable and necessary.  At the same time, we also do believe that done manually, E/M coding is error-prone and that EHR coding decision support assists in the selection of a level of service that is more consistently an accurate reflection of the appropriate services delivered and documented.  This addresses the pervasive problem we saw in our own practices prior to EHR adoption in which providers systematically under-coded their paper chart-based encounters because of: 1) the time inefficiency of documenting all of the relevant findings; 2) the challenges of locating and documenting the review of all relevant results and reports; 3) difficulty in accurately coding visits according to complex billing regulations; and 4) fear of prosecution and reputational harm from accidentally over-coding visits. 

With accurate real-time coding software in their EHRs, such providers find themselves no longer caught in the regulatory ‘speed trap’ of complex coding rules. They now have the equivalent of a coding ‘speedometer’ that allows them to confidently bill at the level where they should have been billing for such visits for years but had been afraid to.  The same decision support can also alert them when they are coding ‘over the speed limit’ and encourage them – not to go back and fraudulently document  – but to change to a lower E/M code if that is all that can be supported by the work done and the medical necessity of doing it.  We do not want physicians to believe that using the EHR to better document what they are appropriately doing, and then accurately coding for their services will expose them to a new ‘speed trap’ in which such behaviors are considered prima facie evidence of billing fraud, simply because their average coding level is higher since they started using an EHR.

Please continue reading the conclusion of this post, Part 6 , for our comments on the E&M documentation guidelines and “note bloat” – a significant waste of time for note author and reader, as well as a barrier to more efficient use of EHRs; and our conclusions and recommendations for a constructive path forwards.

By Michael Zaroukian, MD, PhD, FACP, FHIMSS and Peter Basch, MD, FACP  

Incorrect Assumptions Lead to Incorrect Conclusions That Misinform Policy

Please refer to Part 1 of this post for our comments on the recent Wall Street Journal op-ed questioning the policy behind the EHR incentive program, and Part 2 for our comments on the extent to which EHR use was associated with higher short term charges, as published in the Center for Public Integrity report and recently summarized in the New York Times, and Part 3 for our comments on where one would expect EHR use to show short-term cost increases.

One of the inferences of the Center for Public Integrity report was that a finding of repetitive language (boilerplate documentation) in medical notes or similar appearing notes should raise suspicion of  fraudulent behavior.   Regarding the issue of extreme repetitive documentation, we agree that it is hard to imagine instances where appropriate documentation is also a complete and exact copy of a previous note, or the exact note (with the name of the patient changed) that can be found in another patient’s chart.  That said, we absolutely expect that parts of many medical notes should include similar if not identically worded phrases and sentences that can be seen in many other notes because medical documentation uses a standard language and boilerplate templates for describing findings.  For example, as medical students we were trained to use a single comprehensive Review of Systems and a single comprehensive physical examination template, and we were criticized for missing components of it. 

Fortunately for patients, physicians are trained to use standard terms to describe and clearly communicate positive and negative findings to each other.  While there can be regional variations, such variations are predictable and comparatively minor.  For example, a patient’s normal lung examination may be documented as “clear” or “clear to auscultation” or “clear to percussion and auscultation” or “clear to P&A” depending on where doctors were trained and how concisely they want to document their normal findings. The same examination may also be expanded eloquently but unnecessarily to “chest/lung examination: inspection reveals no asymmetry, retractions or use of accessory muscles. Palpation reveals no tenderness, crepitance, or tactile or vocal fremitus. Percussion note is resonant with no areas of dullness and with normal diaphragmatic excursion.  Auscultation reveals bronchovesicular breath sounds with normal I:E ratio, and no crackles, wheezes, bronchophony, egophony or whispered pectoriloquy.”  

The medical trainee who did not learn to consistently use standard descriptions and become progressively more concise, or persisted in the use of inappropriate or unclear terminology for each patient (“lungs sound totally awesome but the heart just didn’t sound right!”) would likely flunk out of medical school.  Having ourselves been students who initially used highly verbose descriptions, we were praised in the classroom for our excellent retention of the clinical skills course content and our detailed and thorough descriptions, followed shortly on the wards by corrective feedback or even criticism from residents and attending physicians that our notes were too long to read and took us too long to write, without adding benefits to quality and safety for the vast majority of patients.  Note that “boilerplate language” is used for both normal and abnormal findings as well as much of medical history taking – and this is true whether or not documentation is handwritten, checked off on a paper documentation form, templated in an EHR, or “uniquely” dictated (“please insert my normal 14-part Review of Systems”).  This process of self-discovery of unique verbiage for most encounters is a common EHR implementation practice.  Where providers commonly state a limited number of descriptions of historical or exam findings, it is typical to construct EHR documentation templates with drop-down options to facilitate appropriate documentation using a limited set of most descriptive terms (chest pain could be described with drop-down options such as: dull, sharp, pressure, burning, stabbing, etc.).

So if we can agree that much of medical documentation has always looked more similar than dissimilar between patients and even within the same patient over time – we contend that both of us may well be repetitively and accurately described over the last several decades in our respective medical records as a “well-developed, well-nourished man in no acute distress” – the difference between handwritten paper notes and EHR documentation is that with the latter, one now has the ability to actually read the documentation, so perhaps the realization that we say mostly the same things much of the time is a “downside” of legibility.  We would argue that when the lungs are clear to percussion and auscultation or a holosytolic, grade II/VI murmur is present and best heard at the left lower sternal border and apex, it is both appropriate and a best practice to describe these findings the same way each time they are documented, and they should be documented every time they are relevant to the visit.  The patient’s health will not be served by creative writing that is potentially confusing or wastes time. 

For the record, it is our view that ‘copy forward’ and ‘copy-and-paste’ EHR functionalities are just tools that can be used appropriately or inappropriately. Used appropriately and with modifications that bring the data they contain up-to-date, these functionalities can contribute to more efficient, consistent and complete documentation of important conditions and findings. Used inappropriately, they can be inaccurate, unsafe, and contribute to fraud and abuse.  The reality is that this is potential exists for the entire EHR and for paper charting systems, which can be used inappropriately to enabling the authoring of ‘science fiction’. As such, we would argue that copy-and-paste and copy forward capabilities of EHRs, like scalpels that can also cut both ways, should be available to those trained and committed to using them correctly and to good purpose, and withheld from those who are unwilling or unable to use them according to expectations. 

Seeing similar terminology across patients or within the same patient over time is NOT prima facie evidence of fraud; it is prima facie evidence that the author of the notes graduated medical school.  Depending on the setting and scope of practice, notes for different patients with the same problem will look more alike than different and for the same patient over time, except where there are acute changes or illnesses, much of the normal, chronic or unchanged findings documented in the note should appear pretty much the same from the previous note.  As stated in each of the prior parts of this post, we take intentional billing fraud seriously, and would join the call to develop software that helps to illuminate and address potential fraud.  That said, such software that looks for common terminology, phrases, or even similarity in full notes would detect appropriate and accurate documentation far more often than intentional fraud.

Please continue to Part 5 for our discussion of coding software, and on view on the call to regulate its use.

Peter Basch, MD, FACP and Michael Zaroukian, MD, PhD, FACP, FHIMSS

Incorrect Assumptions Lead to Incorrect Conclusions That Misinform Policy

Please refer to Part 1 of this post for our comments on the recent Wall Street Journal op-ed questioning the policy behind the EHR incentive program, and Part 2 for our comments on the extent to which EHR use was associated with higher short term charges, as published in the Center for Public Integrity report and recently summarized in the New York Times.

As we left off in Part 2 of this post, the finding of the OIG that 0.38% of providers had aberrant billing profiles was somehow inferred to be related to EHR use (if the OIG found that to be the case, we cannot find that association in the source documents), with the further inference that this was unexpected and needed to be corrected.  As we affirmed repeatedly in Part 2, where the EHR, billing software, or just deceitful practices lead to intentional fraud, we join the call of Attorney General Holder and Secretary Sebelius to bring such practices to an end.  Indeed, at least some of those providers in the highest coding group of 1,669 physicians reported by the OIG are likely to be knowingly, deliberately and consistently documenting care that was not delivered or not necessary and then using the coding software in their EHR systems to ensure that the fraudulent documentation supported the E/M code that was used, making it harder to detect their fraud.

Let’s imagine that the OIG actually had reported out something very different (which they did not); that early data (let’s assume for a future report in 2014) showed that EHR users, particularly those in the fields of family medicine and internal medicine showed a higher level of charges than their colleagues still on paper records.  This of course would be followed by comments from policy makers about the lack of foresight in scoring the HITECH Act, and the failure of EHRs to curb costs. 

For those not familiar with the theory of how EHRs could curb costs, below are some of the ways (not an all-inclusive list):

(1)    Widespread interoperability would make results available to authorized providers such that test and procedure redundancy could be greatly reduced.

(2)    Decision support could be used such that overused, misused or unnecessary tests or procedures could be successfully discouraged from use.

(3)    Secure messaging and other technologies that enable less expensive, non-visit based care could be used when appropriate.

(4)    Clinical decision support to optimize care could help to prevent adverse drug events and other medical mishaps that lead to expensive emergency department visits, hospitalizations, prolonged  hospital stays, re-admissions, long-term disability and deaths.

(5)    More consistent use of medication formularies and use of generic medications could reduce drug spending.

(6)    Clinical decision support, particularly for primary care providers, will increase the percent of patients getting appropriate and necessary preventive and chronic care services.

As we mentioned in Part 1, it is nonsensical to look for results (positive or negative) where there is no chance of seeing them; thus, if one were looking for cost reductions enabled by EHRs, one would conclude that many of the gains would not be seen in the short-term, except perhaps from formulary adherence or use of generic medication.  If we then return to our hypothetical 2014 OIG report above and assume that OIG found that there were statistically more charges for EHR users than for physicians on paper records, particularly for those physicians in family and internal medicine, would this be a cause for alarm? Should it generate another call for the government to revisit the wisdom of its EHR incentive program?  Absolutely not; it would more likely be an early indicator that EHRs were being used as more than documentation tools (which is of little direct value to the patient), and instead as tools to improve quality, safety and efficiency.

There is an abundance of evidence that primary care doctors in the US are systematically undertreating their patients.  Most studies confirm that only about 50% of patients consistently receive appropriate and medically necessary preventive services, and somewhat less than 50% with chronic illness receive appropriate management of those illnesses.  The implication of this lack of consistent application of preventive and chronic care services is that there is a price to be paid for underuse of services as well.  The cost of inattention to appropriate and necessary preventive care and screenings, as well as failure to appropriately manage chronic illnesses, comes at a high cost – such as  failing to find and/or manage cancers when they are more easily treatable or curable, or inadequate inattention to preventing or treating chronic diseases that are then more likely to result in serious, debilitating and costly sequellae for patients, their families, and payers.   

In the primary care fields, one design approach to optimize the value of EHRs is to recast every opportunity with a patient as an opportunity to address all unmet care opportunities and goals.  The concept is shifting from what we know now doesn’t serve patients well, a reactive system of care in which we only focus on patients when they perceive themselves as sick, and we only treat what they perceive as a problem.  Thus, a patient who only went to the doctor for respiratory infections and other complaints may never get cardiovascular and cancer screenings.  A more recent approach, not invented by the EHR but made more achievable with EHR systems, is what is called a “shared agenda visit.”  This means that although patients still come to the physician as needed for sick care, the physician uses the EHR to identify specific care opportunities and unmet goals.  When appropriate and feasible, the provider then expands the acute care visit to include whatever preventive and chronic care needs are indicated and when this is not practicable, recommends another visit in a timely manner.  For example, a patient coming to the doctor for back pain may also have cancer screenings scheduled, as well as appropriate follow-up exams and testing for diabetes and hypertension.  Depending on the number of chronic care conditions addressed and how they were managed, under the current coding guidelines, you would expect that shifting to an outcomes-focused shared agenda model will lead to short-term increased costs.

Another concrete and timely example can be seen with Million Hearts™.  For those not familiar with Million Hearts™, it is a program developed by HHS (in conjunction with the American College of Cardiology and the American Heart Association) built on the premise that more consistent attention to four health concerns (aspirin use to prevent heart disease, blood pressure screening and control, cholesterol screening and control, and smoking cessation – collectively known as the “ABCs”) can help to prevent one million new heart attacks and strokes over five years.  We know that within the US, only 47% of patients who may benefit from aspirin for primary prevention are taking it; only approximately 50% of patients with hypertension have their blood pressures controlled; and only about one-third of patients with high cholesterol levels have them controlled.

One of us (PB) is launching a Million Hearts™ program across all of his health system’s primary care sites.  This means that every adult patient seen by our primary care doctors will have over the course of each year, all of his or her “ABCs” addressed.  Over the short-term, will adherence to this program result in higher costs?  Absolutely.  We expect to have more visits, more testing where it was previously not done, and in at least some instances higher complexity visits.  That said, the short-term cost increases would be more than made up if they indeed led to success in preventing our share of the estimated million new heart attacks and strokes that would otherwise occur.

Please continue to Part 4 for our discussion of repetitive or “boiler plate” documentation, and whether that should be considered as prima facie evidence of documentation fraud.

By Michael Zaroukian, MD, PhD, FACP, FHIMSS and Peter Basch, MD, FACP

Incorrect Assumptions Lead to Incorrect Conclusions That Misinform Policy

Please refer to Part 1 of this post for our comments on the recent Wall Street Journal op-ed questioning the policy behind the EHR incentive program.

The Center for Public Integrity report (recently summarized in the New York Times) does not question the rationale behind the EHR incentive program, but instead presents the “unexpected” finding that whatever policy makers were hoping for, there is current evidence that doctors and hospitals using EHRs are in fact billing for more and higher complexity services – and are thus increasing costs.  The article suggests that much of the higher billing is the result of electronic ‘science fiction’ in which medical scientists (doctors) electronically record findings without actually ascertaining them, raising the specter of EHRs as a new and significant cause of billing fraud. 

We wish to make it clear from the outset, medical billing fraud is a criminal activity that illegally diverts dollars out of our healthcare system; and by doing so, hurts everyone.  We thus applaud the speed and clarity with which Attorney General Holder and Health and Human Services Secretary Sebelius have made it clear that such fraud will be vigorously sought out and prosecuted.  That said, we submit that the loaded term “billing fraud” means different things to different people, and it is that lack of clarity that explains the intense reaction to this report.  We offer the following two as examples of billing fraud, and instances that the warrant the swift and appropriate action, as announced by Attorney General Holder and Secretary Sebelius:

1. The patient doesn’t exist, or the patient exists but did not have the services that were billed for on that day.  This group does not include patients where there is question as to the appropriate level of service.  This type of fraud is almost always criminal behavior or a gross and negligent error.  This existed prior to EHR systems and electronic billing and is not cured by them; indeed, it can be made worse with electronic charge capture and billing systems.
2. The patient exists and had a billable service with a provider in which the provider deliberately and intentionally over-documented elements of history, examination, medical decision making or time-based services. This can be done efficiently in a paper-based charting system (paper forms with checkboxes that are ‘pencil-whipped’), templated dictation and transcription services that are fictional, or in an EHR.  In such cases, the hallmark behavior is the documentation of findings or actions that did not actually occur or were not medically necessary given the patient’s conditions, and were done solely and effectively to justifying a higher billing code for the encounter than would otherwise have been justified.  This too is clearly unethical and unprofessional, and while it is not unique to documentation using EHRs, it has likely been further enabled by the technology.

So indeed we can all agree that these instances would most likely represent criminal, negligent, unethical, or unprofessional behavior.  That said, what exactly was uncovered by the Center for Public Integrity?  In calendar 2010, the Office of the Inspector General (OIG) found that 1,669 (0.38%) of 442,000 physicians had Medicare billing profiles that differed significantly from their colleagues, billing at the highest two E&M codes 98% of the time (with total payments of nearly $108 million), compared to others who billed these codes 53% of the time; these physicians were found primarily in the specialties of emergency medicine, family medicine, and internal medicine.  The OIG report did not look at the EHR and billing software use by physicians so we cannot know if there is any relationship between the use of such software systems and disproportionate use of higher billing codes from these data.

This does not mean that the report could not be used to draw disturbing inferences in this regard, even if such conclusions require the use of conflated logic.  For example, in both the New York Times article and the Center for Public Integrity report, it was stated correctly that many of the physicians in this extremely small fraction of billing outliers were emergency medicine physicians.  The New York Times reporters then correlated Baptist Hospital in Nashville’s 82 percent increase in use of highest level coding in 2010 with its recent implementation of “a software system for its emergency room records”, although the reporters did not specify whether the software system was an EHR, an electronic coding system, or something else. 

The reporters also appeared to attempt correlate the government EHR incentive program as being temporally or causatively associated with the increased use of higher billing codes, reporting that “hospitals that received government incentives to adopt electronic records showed a 47 percent rise in Medicare payments at higher levels from 2006 to 2010”.  What they failed to mention is that any such correlation would be spurious because this timeframe predated the CMS Meaningful Use Incentive Program; the Final Rule for Meaningful Use Stage 1 was not released until the summer of 2010, and 2011 was the first year of incentive payments.  There was also no attempt to explain the finding that hospitals that have not yet received any Meaningful Use incentive payments also had a significant increase (32%) in use of higher billing codes. Finally, the 47 percent statistic was nonspecific about the types of payments that were included.  This matters not only because Medicare Part A hospital payments dwarf Part B physician payments – making the maximal overall contribution of any inappropriately higher physician E/M payments small – but also that if Medicare Part A hospital charges are included, they would be unrelated to physician billing practices and may or may not have any relationship to the presence or absence of EHR systems.

So while we would agree with the OIG report statement that “E/M services have been vulnerable to fraud and abuse” (as are virtually all payment transactions), we feel it is scientifically irresponsible to combine its findings with anecdotal stories and pessimistic views about how possible and “widespread” it “might” be that such systems are used for illegal purposes by a significant but largely invisible population of unscrupulous physicians using EHR systems that specifically encourage providers to document what wasn’t done or wasn’t necessary. 

It bears restating, neither we nor any other responsible provider or healthcare organization condones intentional billing fraud.  The OIG report did not suggest that these aberrant billing profiles had anything to do with EHR use and the OIG cannot even know yet whether the higher billing codes used were inappropriate.  But for the sake of argument, let’s assume there was an association (as many of the interviewees assumed) between EHR use with E/M coding decision support and higher billing levels.  Are there legitimate and even expected reasons why billing levels might increase and those short-term increases may actually be associated with longer-term savings?

Please continue to Part 3 for our comments on EHR use and increased short term costs.

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 been broad consensus that widespread adoption of electronic health records (EHRs) is a necessary step in the evolution to better, safer and more affordable care…at least until last week, when two reports were published that appear to question that conventional wisdom.  The first, published as an op-ed piece in the Wall Street Journal, appears to center on a recent systematic review of research articles containing economic analyses of EHRs and health IT systems, specifically looking to see if study interventions were associated with lower costs for medication management. The editorialists concluded 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 report, from the Center for Public Integrity and published in the New York Times, does not question the rationale behind the policy but instead presents the startling and disturbing finding that whatever policy makers were hoping for, there is evidence that doctors and hospitals using EHRs are in fact billing for more and higher complexity services – and are thus increasing costs.  Worse, the New York Times article suggests that much of the higher billing is the result of electronic ‘science fiction’ in which medical scientists (doctors) electronically record findings without actually ascertaining them.   We will focus here on a critique of the Wall Street Journal op-ed piece. In Part 2 to follow, we will provide a perspective on the Center for Public Integrity report.     

What do we know of the potential benefits of health IT and EHRs? They are now understood to be supportive infrastructure (i.e., tools) that can facilitate delivery, documentation and payment for health care services.  As tools, they have no independent ability to make care better or worse, or make care more or less expensive.  We also know that just like other tools, simply making EHRs better will not necessarily make care better, safer, or more affordable.  However, there is evidence that well-designed and deployed EHRs and supporting health IT in the hands of trained professionals committed to using these tools wisely and well can facilitate care that is more effective, efficient, safe, timely, equitable and patient-centered.  

How EHRs are used and whether they appropriately or inappropriately increase or decrease physician and hospital billing depends significantly on the healthcare delivery system in which they are used, the EHR training and proficiencies of users, the accuracy and completeness with which clinicians document their findings, and the alignment of financial incentives with specific provider actions.  While time-limited financial incentives (defined as short term extra payments or penalties) are a small component of achieving financial alignment with policy goals, the most significant contributor to improved practices is the sustainable business case – namely the provider payment system.

Thus, where physicians and hospitals are paid only for the volume and complexity of services delivered, one could expect that EHRs would be used to support higher volumes and increased documentation of more complex care, particularly when payment is proportional to the extent of documentation.  One would also expect to consistently see the converse – EHRs being used to reduce unnecessary and inappropriate services and complexity – when the payment system is closely aligned with these objectives.  This is exactly what is increasingly seen in studies that analyze settings of care based on the payment model.  Specifically, studies done at health systems such as Kaiser (which is both a provider and payer) more consistently and reliably show reductions in unnecessary volume of services and avoidable cost while demonstrating high levels of quality.

What problems did we have with the Wall Street Journal op-ed article?  From our perspective, there were three major flaws.  First, we believe the editorialists drew an inaccurate and misleading conclusion from the systematic review when they wrote that “a comprehensive evaluation of the scientific literature has confirmed what many researchers suspected: The savings claimed by government agencies and vendors of health IT are little more than hype.” As evidence, we offer our own summary of the systematic review summarized in the op-ed piece. In conducting this review, the investigators electronically screened over 35,000 potentially relevant citations, finding only 31 (<0.1%) that contained cost data and an evaluation of the costs. However, they found that the methods used in the various studies were so heterogeneous that they could not be synthesized and so they were forced to limit their analysis to a narrative review. Most studies (74%) included in the systematic review were conducted in U.S. hospital settings and most (61%) focused on computerized decision support systems (CDSS). Only five studies included a full economic analysis. 

The authors concluded that the quality of the economic literature in this area is poor and that a few of the studies they analyzed may offer cost advantages despite high technology acquisition costs. They otherwise indicated that study designs and other factors made it difficult to reach any definitive conclusion regarding cost-effectiveness, cost-utility or cost-benefit of computerized medication management systems and that more rigorous studies were needed to address whether health IT interventions for medication management are cost-effective. The authors acknowledged that there was no attempt to look at costs associated with other types of orders, the effect on selection of more appropriate therapy, adherence to guidelines, or other economic factors. 

So does this review support the op-ed conclusion that the “savings claimed by government agencies and vendors of health IT are little more than hype”? We don’t believe so.  Instead, we gleaned the following take-away messages from the systematic review: 1) there have been very few economic studies of medication management in EHR systems; 2) the methodologies used to conduct such analyses have not been consistent, making it difficult to combine the data and draw definitive conclusions; 3) a significant fraction of the studies focused only on certain types of medication therapy (antibiotics), care settings (hospitals) or types of medication management tools (CDSS); 4) there was evidence of cost advantages in some of the studies; and 5) that additional, more rigorous studies are needed to determine the cost-effectiveness of currently deployed health IT for medication management. 

Second, with regard to the systematic review upon which the op-ed piece was based, we would contend that the authors were looking where one could already predict something would be unlikely to be found, namely decades of research and tens of thousands of citations, only a tiny fraction of which related to the research question, used dissimilar methods and only a handful (5) of which included a full economic analysis that at best could only be applied to a fraction (hospitals) of care settings, with no more than two research studies exploring the same category of clinical decision support (CPOE = 2, computerized reminders = 2, and CDSS = 1). Giving significant weight to these predictably negative or inconclusive findings is scientifically inappropriate. For example, the op-ed authors emphasized the multi-decade span of citations screened rather than the more focused timespan of articles reviewed.  Of the five full economic analyses that were reviewed, four were published between 2004 and 2008, and only one earlier (1992).  None were conducted using systems whose features and functionalities were shaped by the specifications of the HITECH Act or CMS Meaningful Use incentive program objectives or measures. Both of the two CPOE studies showed significant cost benefits, one in savings from prevention of adverse drug events and the other in the costs related to medication prescribing errors. The study that examined computerized medication reminders involved an intervention to improve tetanus immunization with the primary outcome being improvement in immunization rates rather than costs. One would expect that this computerized reminder study would not show a positive cost-benefit outcome because the intervention was not very effective using either computerized or non-computerized methods (<30% net improvement in immunization verification or administration rates), the condition for which prevention of illness would have resulted in large savings (tetanus) was too rare (0.10 cases/million population) to be expected even in a population 1000 times the size of the one studied, and the intervention could have easily been one that has already been shown to be sensitive to the method by which a reminder is presented.  

To us, claiming that negative studies such as the tetanus immunization computerized reminder study is conclusive evidence that EHRs do not save money and that all such claims are “hype” is no more logical than concluding that light bulbs on average do not light up a room because they were not demonstrated to do so in studies that included settings where the bulb was dead or the light switch was turned off.   To imply that one’s conclusions reflect four or five decades of research, thereby lending additional validity and finality to the conclusions when even a cursory read of the systematic review indicates otherwise suggests at a minimum a lack of understanding of EHR history and design.  With rare exceptions, EHRs were not designed to even consider cost, let alone cost reduction strategies (value decision support) until perhaps the last decade, and even then only in earnest after the HITECH Act was passed in 2009 and the CMS Meaningful Use Incentive Program goals, objectives, measures and payment criteria were finalized in 2010.  This is underscored by the finding of economic data in less than 0.1% of the 35,510 citations screened for the systematic review. Further, if a physician has never been trained to consider cost reduction strategies (e.g., to consistently use lower cost medications when possible and not contraindicated) in her/his decision making, it is not reasonable to expect that merely changing the ordering process from paper to electronic would reliably change behavior.

Third and most important, even though the editorialists arrived at this conclusion for the wrong reason, most policy makers have matured their vision of health IT to arrive in nearly the same place – that health IT is at best an enabling infrastructure to the delivery of higher quality, higher value care.  In fact, the policy underpinnings of the HITECH Act (which includes the EHR incentive legislation) are based on that kernel of truth in the Wall Street Journal op-ed – there is sufficient evidence to conclude that EHRs in-and-of-themselves will NOT reliably lead to better, safer, and more affordable care just by their mere presence in hospitals and physician practices.  Thus, 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 (including findings from Institute of Medicine Reports) to enable better, safer and more efficient care. 

We would like to offer a better and more constructively focused editorial headline related to this new systematic review analyzing EHR use for cost reduction in the areas of medication management: “Systematic Review Underscores Paucity of Research Data on the Costs, Effectiveness and Benefits of Computerized Medication Management Systems but Hints that in Some Settings Substantial Savings May be Possible and are Deserving of Additional Study”.

We encourage you to continue reading about this topic in Part 2, where we will tackle the recently published report by the Center for Public Integrity reporting that physicians and hospitals using EHRs show higher charges than their colleagues using paper records.

 Learnings from these challenges included:

• EHRs must continue to be refined to make documentation easier and more intuitive;
• Data entry (note writing) is always painful, and never a way to demonstrate benefit of an EHR; and
• Documentation as the driver of physician activity (defining the basis for payment as per the 1995 and 1997 E&M documentation guidelines) is a big part of the problem.  It makes documentation difficult on paper; and for EHRs it results in either even ‘clunkier’ documentation or just ugly notes.

Additionally, documentation challenges almost never allowed for a basic benefit of electronic systems to be displayed – “write once, use many times.” And that, coupled with another key principle– training and experience matter– led to another conclusion…  While scribble on paper could almost always trump any EHR for documentation ease of an acute visit for a new patient; documentation of return visits in the hands of well-trained and experienced users could be faster than scribble.  Thus, our final, final answer to the question of “does EHR use add time to a doctor’s day” aside from “it depends” was “for most docs, after a period of training and use, productivity (as the proxy for documentation effort) returns to baseline.”

Of course because healthcare processes aside from documentation were never considered “on the table,” few of us ever considered that EHR use could be significantly faster than paper records. 

In 2003, I gave a presentation to the eHealth Initiative titled “Frictionless Medicine: Using the EMR to Decrease Process Friction While Increasing Quality Friction.”  The themes of the talk (as evidenced by the title)… we have friction / barriers in the wrong place in the delivery of care.  Documentation is hard and time consuming; but there are no guardrails when making top-of-mind decisions that could have enormous impact on quality and safety.  Prescribing Claritin (at that point the only prescription non-sedating antihistamine and no comparable OTC choices) was a nightmare requiring phone calls, paper forms, repeat calls, etc.; yet prescribing warfarin without an indication, target range, last INR, etc. was effortless.  My thesis… if we want to use EHRs to make care better, even the most elegant solutions will add time at the point-of-care; and to create the time and space such that EHRs are used optimally,  we must strive to also use them to decrease unnecessary process friction.  Of course reducing what I termed “process friction” had previously been described as “administrative simplification,” which should have been implemented with HIPAA, but for a variety of reasons never actually happened.

Fast forward to yesterday…    

I had the good fortune of being asked by David Cutler (Professor of Economics at Harvard) and one of his doctoral students, Beth Wikler, to contribute to a paper on that aspect of healthcare delivery that most of us never ponder, the world of administrative burden and what is needed to reduce it as much as possible.  That report “Paper Cuts” was released yesterday by the Center for American Progress (full pdf may be downloaded at http://www.americanprogress.org/issues/2012/06/pdf/paper_cuts.pdf).

Aside from the clear financial benefit that would benefit all stakeholders (and thus allow for more actual care to be provided to more patients); I was particularly struck by the findings regarding time and effort burden on doctors and their staff.  Quoting from the report, “Physicians in the United States spend an average of 43 minutes per day, or three weeks per year, interacting with health care plans. This is in addition to the 21 hours that nursing staff and 53 hours that clerical staff spend per physician per week on administrative transactions, particularly claims and prior authorizations.  This time spent on excessive administrative processes is expensive, resulting in less clinical time, less time reviewing and acting on quality initiatives, higher overhead costs, and lower quality of care.”

While we have been busy conducting EHR documentation challenges and determining how to make EHR use time-neutral at best, most of us have neglected to aggressively pursue this aspect of administrative care delivery reform (started by HIPAA and strengthened by the Affordable Care Act).  My comment at yesterday’s press event…  “Every minute devoted to unnecessary administrative burden is a minute not devoted to patient care; every dollar spent on unnecessary administrative burden is a dollar not spent on patient care.”

So back to the title of this blog post, “What could you do with an extra 43 minutes each day?”  In 2003 McGlynn and others woke up many in healthcare with the disquieting assertion that while we think we do the right thing all the time for our patients; we don’t.  Specifically, we provide appropriate preventive and chronic care services only ~ ½ the time. Shortly after the publication of this article, there were two articles in the family medicine literature that together estimated that to do everything that Dr. McGlynn suggested would add an additional 4-17 hours to each doctors day…  essentially countering her findings with “that may be true, but it is not possible.”

In a small scale study at my health system, we found that using an electronic health record embedded with targeted clinical decision prompts and support, we could achieve most of what Dr. McGlynn referenced, but in a far shorter time – approximately 45-60 extra minutes each day (instead of 4-17 hours).  So I want every one of those 43 minutes back.

Without a sustained commitment to reducing administrative burden, it will not happen; and without that reduction in burden, we may never have a healthcare system that is patient and consumer friendly, and is optimized for quality and safety.