By Deborah Hill, MBA, CMPE, CPC, CPC-I
Beginning in fiscal year 2011, one of the major components of the American Recovery and Reinvestment Act of 2009 (ARRA) will come into play as $17 billion in reimbursement incentives offered through the Health Information Technology for Economic and Clinical Health Act (HITECH) start to pay out.
These incentives, payable over a five-year period, may total $40,000 to $65,000 for a physician practice and can amount to several million dollars for hospital systems. To be eligible, physicians and hospitals must be able to show they are “meaningful” users of certified electronic medical record (EMR) technology. These reimbursement incentives will decrease annually until 2015, when practices and hospitals will be penalized via their Medicare payments if they have not implemented a certified EMR.
To take advantage of the incentive initiative, practices and hospitals across the country are in various states of EMR analysis and implementation. To analyze and implement an EMR program successfully, it’s imperative that the pitfalls of such programs are understood clearly so that realistic expectations can be established from the very beginning of the process. This article outlines not only the key considerations associated with the transition process, but more specifically the problems related to coding and documentation.
The implementation of an EMR affects every facet of medical practice and healthcare delivery, including scheduling, communicating with patients and other healthcare providers, patient and staff workflow, billing and collections, coding and compliance. Seeing patients during such reengineering of the practice can be difficult for physicians, staff members and patients if proper planning is not initiated. This is probably the most important pitfall to successful EMR implementation: Without a roadmap to your final destination, the trip can be full of numerous wrong turns and ultimately could take twice as long.
Many practices make fatal mistakes that result in a failed EMR implementation, simply because key questions aren’t addressed in the very beginning. Vendor representatives are highly skilled at focusing on the positives and leaving out the details that create confusion and frustration after the contract has been signed. Careful planning and consideration in the following areas will help reduce unnecessary interruptions to patient care.
Here are some questions to keep in mind. Are there operational issues that could compromise the process? Were the practice objectives clearly outlined? Was the vendor selected based on their ability to meet those objectives? Were all the “costs” considered in the proposal process and were appropriate resources allocated to cover these costs? These costs include:
- Software and hardware
- Initial decreases in productivity
- Annual fees
- Customization fees
- Interface and integration fees
- Transaction fees
In addition, was the vendor researched thoroughly before signing the contract, including checking randomly selected references? Have they kept their promises to clients and been accountable for past implementations? Were the physicians and staff included in the implementation planning? Is there an EMR champion onsite?
During the implementation planning process, it’s important to recognize the conversion from paper to electronic format could affect your staff in various ways, depending on their exposure to and knowledge of electronic technology.
Physicians that completed their medical training in the last 10 years will be much more receptive to these changes because many medical programs have been using electronic records for many years. Those that have practiced in the paper world for years will have a harder time adjusting to all the changes that an EMR will bring. The generational differences in staff also will be more emphasized, so it’s important to recognize these differences at the onset and take extra measures to ensure all staff and physicians have the necessary training they need to increase their understanding and efficiency.
From a coding perspective, EMRs are both a blessing and a curse. Coders initially are pleased to see full historical documentation, including the history and physical exam, are included in the notes. These typically have suffered most in written documentation. Physicians can see all past, family and social history at a glance and even can copy this information into today’s note to save time. They are reminded of chronic conditions when preventive services should be delivered, and can track and adjust all prescriptions with one click. Although this sounds magical—and every EMR vendor will emphasize the improved documentation will justify higher level E/M codes which will result in increased revenue (helping to offset the cost of the product)—there are some serious pitfalls to allowing all the automation these systems currently offer.
Although it is true that physicians across the healthcare continuum have been undercoding their services for years, the sad fact is many physicians still do not have a clear understanding of how to substantiate medical necessity via the documentation in the medical record. Countless hours have been invested in teaching physicians how to interpret the E&M documentation guidelines outlined on various Medicare websites, and to translate those guidelines into user friendly information.
