The Pros and Cons of Electronic Health Records
An electronic health record (EHR)—sometimes called an electronic medical record (EMR)—allows health-care providers to record patient information electronically instead of using paper records.1 It also has the capability to perform various tasks that can assist in health-care delivery while maintaining standards of practice. The Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted under the American Recovery and Reinvestment Act of 2009 (Recovery Act), established a provision for incentive payments for eligible professionals (EPs), critical-access hospitals (CAHs), and eligible hospitals if they can demonstrate meaningful use of certified EHR technology:2
- The use of a certified EHR in a meaningful manner (e.g. e-prescribing);
- The use of certified EHR technology for electronic exchange of health information to improve quality of health care; and
- The use of certified EHR technology to submit clinical quality and other measures.
Eligible professionals must satisfy 20 of 25 meaningful-use objectives (15 required core objectives and five objectives chosen from a list of 10 menu-set objectives).3 Eligible hospitals and CAHs must achieve 19 of 24 objectives (14 required core objectives and five objectives chosen from a list of 10 menu-set objectives).3
It seems that any program implementation with the potential to generate new or additional payment also has the potential to generate new or additional scrutiny of its application to ensure the generated payment is appropriate.5 Issues with EHR that recently have been highlighted include copy-and-paste, pulling notes forward, and upcoding based on volume instead of necessity.
Consider the Case
A patient is admitted to the hospital for pain, warmth, and swelling in the left lower extremity; r/o deep vein thrombosis (DVT) versus cellulitis. The patient’s history includes peripheral vascular disease (PVD), chronic renal insufficiency (CRI), and allergic rhinitis (AR). Testing confirms DVT, and the patient begins anticoagulation therapy. To achieve a therapeutic balance and prevent adverse reactions, the hospitalist orders INR monitoring.
On admission, the complexity of the patient’s condition may be considered high given the nature of the presenting problem.4 The hospitalist receives extensive credit for developing a care plan involving differential diagnoses with additional testing in anticipation of confirming a diagnosis. The patient’s presenting problem elevates the risk of morbidity/mortality, while the determined course of anticoagulation therapy places the patient at increased (i.e. “high”) risk for bleeding and requires intensive monitoring for toxicity. In this instance, 99223 may be warranted if the documentation requirements corresponding to this visit level have been satisfied.
As subsequent hospital days ensue, the complexity of the patient’s condition may not be as high. Even though the risk of anticoagulation remains high, the number of diagnoses and/or data ordered/reviewed may be less extensive than the initial encounter. Therefore, without any new or additional factors, the overall complexity of decision-making may be more appropriately categorized as moderate or low (e.g. 99232 or 99231, respectively).4
Do not fall victim to shortcuts that may falsely ease the workload of the overburdened physician. For example, the patient’s co-existing conditions of PVD, CRI, and AR likely were addressed during the initial encounter for DVT with inclusion in the plan of care. When using an electronic documentation system, it might be possible to copy the previously entered information from the initial encounter into the current encounter to save time. However, the previously entered information could include elements that do not need to be re-addressed during a subsequent encounter (e.g., AR) or yield information involving care for conditions that are being managed concurrently by another specialist (e.g. CRI being managed by the nephrologist).
Leaving the pasted information unaltered, without modification, can misrepresent the patient’s condition or the care provided by the hospitalist during the subsequent encounter.
