Podcast Episode 6: EMR Best Practices (EMR Part I)

Episode Summary: Electronic Medical Record software has the potential to facilitate documentation and minimize errors. EPIC is the most widely used EMR in the United States. There are other EMR vendors. Despite their pervasiveness in healthcare, documentation quality in EMRs is often poor and prone to error propagation. A clear understanding of proper documentation is necessary for proper medical coding. Hosts Neal Sheth and Dr. Piyush Sheth explore EMR best practices as they relate to patient care and medical documentation.

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Hosts: Neal Sheth, MBA, CGSC; Piyush Sheth, MD, FACS, DABS, CGSC

NEAL SHETH: How can the complexities of medical documentation and coding be simplified? Can healthcare providers and professional medical coders maintain efficiency in an environment of ever-increasing complexity? This is Unraveling Medical Coding and I’m your host and Certified General Surgery Coder, Neal Sheth.

PIYUSH SHETH: And I’m Piyush Sheth, a General Surgeon and author of Coding Solutions, General Surgery and Starting Medical Practice.

NEAL: Hi dad.

PIYUSH: Hey Neal. On this episode I’d like to focus on how to improve medical documentation. Specifically, I want to focus on Electronic Medical Records, commonly known as EMRs or EHRs, Electronic Health Records.

Prior to EMRs, healthcare providers documented on paper. Notes, radiology reports, blood test results, pathology results and anything else related to patient care was documented on paper and filed into a patient chart. These paper charts became quite bulky and storage required vast amounts of physical space. One of the significant criticisms of paper charts was related to legibility. I’ve come across notes where even the author was unable to decipher them. Obviously, this poses a hazard to patient care. Imagine a prescription where the pharmacist filled the wrong medication due to unclear handwriting. The result: patient harm.

With the boom in information technology, Electronic Medical Record software was developed in an effort to provide ease in documentation, mitigate medical errors, and allow universal access to medical records. EMRs are great for creating reminders for preventative care and chronic disease management and making repetitive tasks easier to perform, and to boot, documentation is legible. The Goliath in EMRs is EPIC, developed by Epic Systems Corporation in 1979 by founder and CEO Judith Faulkner.

This episode contains some criticism of EPIC. I’m not David…and I’m not here to slay Goliath. What I really want to do is to spark interest in making EPIC more user friendly and returning to the basic premise of making healthcare efficient and error free. There are other EMR vendors. Cerner, Allscripts, AthenaHealth, McKesson EMR, and Siemens Soarian to name a few. My personal experience comes from using EPIC and Soarian.

NEAL: OK. This is where you tell me that EMRs have limitations. Right?

PIYUSH: You’re right Neal. I’ll talk mainly about EPIC because I’ve used it now for the past 7 years. EPIC is built on a programing language from the 1960’s called MUMPS (Massachusetts General Hospital Utility Multi-Programming System) and is a bit archaic. After I was onboarded on EPIC, there was an initial year of headaches and aggravation, but I’ve come to peace with EPIC. It is a beast. In general, EMRs are built primarily for data collection and to satisfy regulatory guidelines. They are tedious to use and not very user friendly. When healthcare providers are faced with sitting in front of computers for hours at a time, they revert to using shortcuts in documentation. When used unscrupulously, these shortcuts make it effortless to commit fraudulent documentation. There is a saying in healthcare, “If it’s not documented, you didn’t do it.” However, with EMRs, you can easily “document what you didn’t do.”

NEAL: So what kind of shortcuts do providers use?

PIYUSH: Documentation templates and “copy and paste” are the two most widely used shortcuts.

NEAL: Can you explain these a little bit more dad?

PIYUSH: Sure. Documentation templates are predesigned word processor templates that leverage dot phrases also known as smart phrases that pull in patient database information into the note automatically. For example, if you want the patient name to show up automatically, you would insert the dot phrase “.patient” into your template. Then whenever you open the template, it pulls in the patient name automatically. Other common dot phrases that are used are “.pmh” for past medical history, “.psh” for past surgical history, and “.famhx” for family history. Templates and dot phrases can significantly lessen the time to document a patient encounter and provide standardization of notes. However, the pitfall in using them is that you have to rely on the accuracy of the information already in the patient database. If the information is incorrect, you would be importing incorrect information into your note. Healthcare providers should know how to update the information in the patient database before they import it into a template.

“Copy and paste” is the other shortcut that providers are taught to use. It is simply the act of copying information from one part of the EMR and pasting it you’re your encounter note. Again, the pitfall is in the accuracy of what you are copying and pasting.

Don’t get me wrong, I’m not saying that we should avoid documentation templates, dot phrases, or “copy and paste”. I use all of those shortcuts myself. All I’m saying is that we need to use these intelligently.

NEAL: So, we need to maintain the integrity of a patient’s EMR. Right?

PIYUSH: Uh huh. This can only be done if all stakeholders, healthcare providers and patients, actively curate it for accuracy. In an attempt to get buy in from patients, parts of the 21st Century Cures Act developed by The Office of the National Coordinator for Health Information Technology that went into effect on November 1, 2020, provides transparency by allowing patients access to their medical record documentation.

NEAL: You mean patients can see the notes that doctors are writing in their chart.

PIYUSH: Yep. And I think it’s great. Patients scrutinizing their own medical information can only make healthcare better. A few months ago, I saw a patient who had part of their large intestine removed. In their EMR chart, they had a diagnosis of colon cancer. When I asked the patient if they remembered what stage their colon cancer was, they responded “I didn’t have cancer. I only had a polyp.” That’s when I started looking through the EMR and I was surprised to find that every single EMR note by healthcare providers had listed that the patient had colon cancer when in fact, there was a pathology report that listed the final diagnosis as a very large polyp without malignancy. I corrected the information in the EMR so that future providers would benefit from the accurate diagnosis. We make decisions based on information and this patient was being seen every 4 months for years because providers incorrectly though he had had cancer and he needed close follow-up. If that patient had access to his chart, the error could have been identified much earlier and corrected and save the patient from numerous unnecessary office visits. It is our responsibility as healthcare providers to ensure the integrity of the data in the patient’s chart.

NEAL: Alright, that’s an interesting story but it probably does not happen frequently.

PIYUSH: You would hope it does not happen frequently. In reality, having a clean patient history is rare. I have been teaching medical students for over 4 years now. For each batch of students, I challenge them to find a chart during their time on General Surgery that has an accurate patient EMR history database. To date, we found only one. That’s a very sobering statistic.

NEAL: OK, so healthcare providers can do better. How do we go about that?

PIYUSH: Well Neal, we challenge them and we ask our EMR vendors to make the EMR user friendly. Two weeks ago, I ran into a physician who has been using EPIC for about 7 years. We had a mutual patient in the hospital and I noticed that his History & Physical note had errors. I didn’t point out his errors. Instead, I asked him if he wanted to up his game with documentation. He was hooked. So, I explained to him that there is a database within EPIC that holds a list of the patient’s medical diagnosis and surgical history. I asked him if he knew how to input new information or correct information in the database and he did not. “No one ever showed me how to do it. The nurses put in that information.” As a physician, he had never corrected or updated information in a patient’s database. He would simply pull the information into his note using a dot phrase or smart phrase and then dictate the rest of his note. Dictating information into a note does not carry information into the database so it gets lost in the vastness of electronic data. For our mutual patient, I showed him how to access that database, correct the contained information, and add meaningful information. It doesn’t take long and every subsequent healthcare provider will benefit from the accurate information.

NEAL: Can you give us some examples of how to leverage EMRs to improve healthcare?

PIYUSH: Sure.

Example 1. I call this one: Too many cooks ruin the pot. In EPIC, healthcare providers accessing the patient’s EMR chart can enter data into a History Navigator tab. Nurses enter information into the Rooming Navigator tab which lists common diagnoses with ‘yes’ and ‘no’ buttons. The patient’s past medical history that is already present is not visible to the nurses and therefore most nurses are not able to confirm that it is new data that they are entering. In contrast, the History Navigator tab allows providers to enter and correct entries, yet most physicians do not even know how to access the tab. These different ways to enter medical history often results in duplicated diagnoses or procedures. It is not uncommon to see a patient with three or four entries listing diabetes, all entered by different providers. This diagnosis should be reflected in a single entry. Have you ever heard of a patient having two hysterectomies? Well, in EPIC, it is possible. The solution is to make entering a patient’s medical history transparent whether you are a nurse or a provider. That way you can see if you are entering duplicate information or not. Also, setting up smart alerts within EPIC can also help. If you are trying to enter diabetes and it is already in the patient’s history, EPIC should be able to alert you with a prompt of “Do you really want to enter this diagnosis based on a similar diagnosis already in this patient’s history?” This functionality currently does not exist. As a computer programmer, I know it can be implemented.

Here’s food for thought. Computers can data mine and process repetitive tasks at blazing speeds. What if Medicare or other healthcare insurance companies mandated EMRs to have functionality in the software that could crawl through EMR patient notes and flag those notes that had duplication errors and then flag those charts for audits. It would certainly simplify the chart selection for audits and probably increase the yield rate of negative audits significantly. Gone are the old days when auditors came to your office and spent hours and days going through paper charts. Now the auditors can access a patient’s chart electronically from their office and with the right tools, speed up the auditing process.

Example 2. A diagnosis of cancer in the history database is usually scant on details. I see very simplistic entries like “Breast cancer”. This is not very informative. As a physician, I’d like to know the type of cancer, stage, surgical treatment, and adjuvant chemotherapy or radiation treatments as well as who the Oncologist is managing the patient. For my patients, I input an entry that goes like this: “Breast cancer, 2018, right breast, infiltrating ductal carcinoma with ductal carcinoma in situ, pathologic stage T2 N0 MX, Stage 1, Estrogen Receptor +, Progesterone Receptor +, Her2neu oncogene unamplified, s/p lumpectomy and Sentinel Lymph Node Biopsy, adjuvant radiation therapy and Tamoxifen, ONCOLOGIST: Dr. Steven James.” You can see how this detail when carried over for all subsequent providers makes it efficient to find quality information that benefits patient care.

Example 3. “Copy and paste” should be replaced with “copy, paste, review, and update.” The Office of the Inspector General in 2014 had the following warning:

“Copy-pasting, also known as cloning, enables users to select information from one source and replicate it in another location. When doctors…copy-paste information but fail to update it or ensure accuracy, inaccurate information may enter the patient’s medical record and inappropriate charges may be billed…Furthermore, inappropriate copy-pasting could facilitate attempts to inflate claims and duplicate or create fraudulent claims.”

What that means is that fraud related to copy-pasting is on their radar. Beware providers. In EMRs, you can copy an entire previous encounter note into a current encounter note. The following example appears sometimes on a third-year medical school exam. A hospitalist writes in his note “patient has right upper quadrant pain, consult General Surgery.” Later that day, the General Surgeon writes “no gallstones, normal liver and pancreatic enzymes. No need for surgical intervention. Signing off.” The next day, the hospitalist note states “patient has right upper quadrant pain, consult General Surgery.” It is very clear that information was copied and pasted without any thought to actually updating the information. Billing for the subsequent hospitalist note could lead to a claim of fraud as it does not reflect a new updated plan. I’ll stress the point one more time: don’t forget to review and update what you have copy and pasted.

Example 4. Use Physical Exam templates carefully. During my onboarding for EPIC, I was told to follow along with a training video of a history and physical encounter. The patient was a male patient. For the physical exam documentation, I was to click on a drop-down selection list. The four selections presented to me were as follows: Male brief exam, Male expanded exam, Female brief exam, Female expanded exam. It seemed odd to me that the software was not limiting the selections just for a male patient. I deliberately clicked Female expanded exam and found a very comprehensive examination had been entered with breast and pelvic exam items. When I told the proctor that my mouse had slipped and asked why it would let me enter a female exam on a male patient, he had no answer. He also could not figure out how to correct the mistake.

My advice to providers is to review the physical exam template information for each patient to make sure it reflects what you actually did.

I once saw a patient who had congenital syndactyly. He was born with only 3 fingers on each hand. The hospitalist physical exam musculoskeletal entry stated: no deformities. The history in the EMR did not even list the patient’s diagnosis of syndactyly. I’m sure the patient was not examined correctly because the syndactyly is hard to miss.

Example 5: Avoid using ambiguous diagnoses and surgical procedures. Entries such as “Disease of the thyroid gland” and “Hernia repair” are essentially worthless. Was it hypothyroidism, Grave’s disease of the thyroid, or thyroid cancer? What kind of hernia was it, inguinal, femoral, umbilical, hiatal, or ventral? To clarify these ambiguous terms, just talk to the patient and examine them. Most of the time they can tell you their diagnoses.

NEAL: Wow dad. It seems we have a lot of issues with using EMRs for documentation. Most of what you are saying seems easy to implement. So why are these issues still prevalent?

PIYUSH: When a healthcare provider starts using an EMR, the complexity of the software mandates more time be spent in front of a computer. To circumvent this, providers have found shortcuts, most of which defeat good medical practice. In our show notes, I’ve attached some resources. The first is called Sheth’s EMR Best Practices where I’ve summarized a host of best practices beyond those that we’ve touched upon in this podcast. And most are easy to implement. I’m also including screenshots of the Rooming Navigator tab and the History Navigator tab for comparison purposes, an eloquent critical analysis of the “cut and paste” technique from the 9th Edition of DeGowin’s Diagnostic Exam, an article from The New York Times titled How Tech Can Turn Doctors Into Clerical Workers, as well as an article from KHN.org titled Death by 1,000 Clicks: Where Electronic Health Records Went Wrong.

Some final words to our audience.

The integrity of the documentation in an EMR is the responsibility of the healthcare provider. When you electronically sign a document, you are in essence putting your reputation on the line.

EMRs are loved by plaintiff attorneys. They look for errors in your documentation and can easily discredit your integrity by pointing out these errors to a jury. Essentially you are giving them a loaded gun to shoot down your defense.

Health insurance company documentation auditors likewise look for these types of errors. If you take credit for performing a past medical and surgical history and it has errors in it, you will not be given credit for billing and they can essentially down code your billing and claim that you are up coding your bills. This could lead to having to pay back the health insurance company and further penalties.

So, ARE YOU READY TO UP THE GAME ON YOUR DOCUMENTATION?

NEAL: Wow. I’m definitely going to scrutinize my medical record chart from now on. Thanks dad, this was quite an eye opener.

We hope you enjoyed this episode. Please check out the other episodes. Don’t forget to rate and review us and subscribe to Unraveling Medical Coding from wherever you get your podcasts. Also, please share this podcast with friends or colleagues who you feel would benefit from learning about medical coding and documentation. Stay safe, and stay healthy.