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A Response to the Call to Action to Improve EHR Documentation

      To the Editor:
      In response to the “Call to Action to Improve EHR Documentation”
      • McEvoy J.W.
      The Turing test and a call to action to improve electronic health record documentation.
      :
      Physicians insert “boilerplate text” (which conveys no new medical information or insights) into their clinical notes mainly to satisfy documentation requirements imposed by the Medicare Evaluation and Management (E&M) Services Guide.

      Department of Health and Human Services, Centers for Medicare & Medicaid Services. Evaluation and Management Services Guide. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/eval_mgmt_serv_guide-icn006764.pdf. Accessed July 28, 2014.

      Medicare and nearly all private health insurers adhere to the E&M Guide to determine their payments to physicians. These E&M service definitions largely dictate the format and content of physicians' progress notes.
      There is tension between physicians, who want to be paid in full for their efforts, and payers, who want to minimize payments to physicians. Payers enforce physician adherence to E&M documentation and billing regulations by hiring clerical employees called “coders” to audit patients' clinical charts for documentation deficiencies. To avoid fines and prosecution, physician notes are usually generated first and foremost to fulfill the requirements of these coder audits, rather than the needs of their fellow clinicians. Coders determine whether a progress note meets the billing requirements mainly by checking how many elements of defined data are present. Most physicians are not completely familiar with the complex, confusing, and arcane E&M requirements, so they load up their notes with as much computer-generated boilerplate as they can, hoping it will include an overlooked element of data needed to satisfy a coder's audit.
      This whole system must be discarded, or there can never be any hope of having progress notes that communicate clearly and concisely between clinicians. A quick and sure way to end this “tyranny of the coders” is for Congress to terminate the exemption granted to payers by the patient privacy laws. This would eliminate inspection of the clinical chart by payers and their coders. Payers would no longer need battalions of coders, who could be relieved of their duties and retrained to perform more productive tasks.
      Payers should not be allowed to read, inspect, or audit patients' clinical charts; this is a violation of patients' medical privacy. It harms patients by causing physicians to spend more of their limited time generating progress notes, leaving less time for interacting with patients. Payers must verify physician billings without violating the privacy of patient charts. Payments could be determined by the average amount of physician time required to treat the patient's illnesses and manage their chronic conditions, as determined from the submitted International Classification of Diseases, 10th Revision codes. Physicians could submit attestations for any required variations. In a world without E&M coding requirements, the clarity and efficiency of clinical documentation could be improved enormously, with more time for physicians to actually examine and treat patients.

      References

        • McEvoy J.W.
        The Turing test and a call to action to improve electronic health record documentation.
        Am J Med. 2014; 127: 572-573
      1. Department of Health and Human Services, Centers for Medicare & Medicaid Services. Evaluation and Management Services Guide. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/eval_mgmt_serv_guide-icn006764.pdf. Accessed July 28, 2014.

      Linked Article

      • The Turing Test and a Call to Action to Improve Electronic Health Record Documentation
        The American Journal of MedicineVol. 127Issue 7
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          Clinical informatics represents arguably the most significant advance in medicine since the deciphering of the human genome. In particular, as the “front end” of the clinical informatics revolution, the electronic health record has immense potential to transform modern healthcare. Demonstrated benefits of the electronic health record include decision support, adverse event tracking, and quality control.1 An additional strength of the electronic health record is an inherent capacity to augment research, including embedded, randomized, controlled clinical trials.
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      • The Reply
        The American Journal of MedicineVol. 127Issue 12
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          In his thoughtful letter, Keller extends the scope of my commentary (discussing current limitations in electronic health record documentation1) to cover the important issue of physician reimbursement. His arguments are germane and complement my position very well. Although I focused mainly on technologic and informatics considerations, Keller astutely notes that an important contributor to the current problem with electronic health record documentation is the external monetary pressure applied on physicians by payers.
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