Electronic Medical Record and Complexity
I've been unable to find the time to blog over the past month because we finally went live with an EMR (Electronic Medical Record) at work. I really hadn't been prepared to the sheer volume of work it would be, both going live and just dealing with the new program. We've had our fair share of bugs--fax servers that wouldn't fax, formatting errors in printable documents, documents that printed to the wrong printers and then printed over and over and over again, VPN connections that wouldn't work or that crashed repeatedly--but underlying it all is the sheer volume of work that we must process every day.
Since starting the EMR, I have determined that I process somewhere close to 40 documents most working days, more on some. I have determined that I also process somewhere between 20 and 30 refill requests per day, as well as field a variety of patient questions. I was doing this work before, but never was able to quantify it. The work would arrive on my desk and I would process it as I could. I told people it seemed like a lot, but I didn't know exactly how much until just now.
I've also determined something else--what I do in medicine is incredibly complex. Our EMR is set up somewhat rigidly, if you want to use the full power of the device. In order to accurately capture billing data, you need to document your work in such a way that the code you charge for your work is appropriate. For instance, coding charges in our current system is based on elements of patient history, which include factors such as duration of problem, onset, character of problem (is the pain sharp or dull?), aggravating factors, associated symptoms, etc. It also is based on the completeness of the physical exam (number of systems evaluated and depth of evaluation), Review of Systems (asking after other symptoms) and consideration of past medical history. Unfortunately, there are very many ways things can go wrong and very many nuances to how they go wrong that our program, complex as it is, is unable to handle.
Most specifically, it's unable to handle it with any degree of speed. The program allows you to click on various elements to the current comlaint, but asking after them is tedious and doesn't follow normal conversational flow with patients. This is in a setting, mind you, of patient care advocates who are telling you you need to let patients explain their history to you without a lot of interruptions. It's a great deal faster if you just type in text while you're talking to the patients. If you can touch-type, that is. Sadly, it makes calculating your proper code harder.
Of course, that doesn't even begin to touch on the annoying subject of assessment and plan. Just finding a diagnosis takes longer than typing in an entire long paragraph describing your reasonin and possible future plans. Mind you, you have to type them in and not pick from a drop down list, because the sheer complexity of that list and how to us it would be mind-boggling.
Here in the United States we have several series of codes used for medical billing system. The CPT codes are the ones used to actually make charges. These include all kinds of codes for things like office visits, procedures (such as suturing), immunizations, injections and other treatments. The other set include the ICD-9 codes, which are the diagnoses. You need both for successful billing. The ICD-9 code book is huge, with an astounding number of codes that cover a great deal of complexity. Despite this, everyday I arrive at some diagnosis that I can't find a code for. Sometimes it's a matter of how I phrase the diagnosis. Sometimes there ijust isn't a code.
For instance, menopausal is listed as "climacteric." Scleroderma, a nasty connective tissue disease is "System sclerosis," something I'm not really sure is specific to the disease itself or maybe just describes the physical findings, which could come from other sources. Other things just pop right up without too much trouble. I still can't figure out why Achille' s tendinitis is so easy to find when trochanteric bursitis, a much more common problem, isn't there at all.
As doctors, we are being called on to do more and more of the work that used to be done by support staff. With our new EMR, we have become even more data entry clerks than before and will be expected to take the place of the transcription service, and most of the medical records department. As we fax prescriptions directly to pharmacies, we will be reducing the workload on nurses, who were calling prescrptions for us and and out patients. If we could do this without adding more time to what we do every day, it might be a win-win situation for our business and ourselves (though not for the people we put out of work). Sadly, I don't see that happening at this point. The more paperwork and other work we do outside of direct, billable patient care, the more resistant we will become to spending more hours in direct contact with patients. And afterall, that was what support staff was originally designed to facilitate.
Since starting the EMR, I have determined that I process somewhere close to 40 documents most working days, more on some. I have determined that I also process somewhere between 20 and 30 refill requests per day, as well as field a variety of patient questions. I was doing this work before, but never was able to quantify it. The work would arrive on my desk and I would process it as I could. I told people it seemed like a lot, but I didn't know exactly how much until just now.
I've also determined something else--what I do in medicine is incredibly complex. Our EMR is set up somewhat rigidly, if you want to use the full power of the device. In order to accurately capture billing data, you need to document your work in such a way that the code you charge for your work is appropriate. For instance, coding charges in our current system is based on elements of patient history, which include factors such as duration of problem, onset, character of problem (is the pain sharp or dull?), aggravating factors, associated symptoms, etc. It also is based on the completeness of the physical exam (number of systems evaluated and depth of evaluation), Review of Systems (asking after other symptoms) and consideration of past medical history. Unfortunately, there are very many ways things can go wrong and very many nuances to how they go wrong that our program, complex as it is, is unable to handle.
Most specifically, it's unable to handle it with any degree of speed. The program allows you to click on various elements to the current comlaint, but asking after them is tedious and doesn't follow normal conversational flow with patients. This is in a setting, mind you, of patient care advocates who are telling you you need to let patients explain their history to you without a lot of interruptions. It's a great deal faster if you just type in text while you're talking to the patients. If you can touch-type, that is. Sadly, it makes calculating your proper code harder.
Of course, that doesn't even begin to touch on the annoying subject of assessment and plan. Just finding a diagnosis takes longer than typing in an entire long paragraph describing your reasonin and possible future plans. Mind you, you have to type them in and not pick from a drop down list, because the sheer complexity of that list and how to us it would be mind-boggling.
Here in the United States we have several series of codes used for medical billing system. The CPT codes are the ones used to actually make charges. These include all kinds of codes for things like office visits, procedures (such as suturing), immunizations, injections and other treatments. The other set include the ICD-9 codes, which are the diagnoses. You need both for successful billing. The ICD-9 code book is huge, with an astounding number of codes that cover a great deal of complexity. Despite this, everyday I arrive at some diagnosis that I can't find a code for. Sometimes it's a matter of how I phrase the diagnosis. Sometimes there ijust isn't a code.
For instance, menopausal is listed as "climacteric." Scleroderma, a nasty connective tissue disease is "System sclerosis," something I'm not really sure is specific to the disease itself or maybe just describes the physical findings, which could come from other sources. Other things just pop right up without too much trouble. I still can't figure out why Achille' s tendinitis is so easy to find when trochanteric bursitis, a much more common problem, isn't there at all.
As doctors, we are being called on to do more and more of the work that used to be done by support staff. With our new EMR, we have become even more data entry clerks than before and will be expected to take the place of the transcription service, and most of the medical records department. As we fax prescriptions directly to pharmacies, we will be reducing the workload on nurses, who were calling prescrptions for us and and out patients. If we could do this without adding more time to what we do every day, it might be a win-win situation for our business and ourselves (though not for the people we put out of work). Sadly, I don't see that happening at this point. The more paperwork and other work we do outside of direct, billable patient care, the more resistant we will become to spending more hours in direct contact with patients. And afterall, that was what support staff was originally designed to facilitate.
posted by Samuraidoctor | 11:52 AM
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