Electronic Medical Record Review

The electronic medical record (EMR) is at the forefront of medical technology. Numerous companies are making it available, and physician groups and hospitals are investigating the potential benefits it can provide. The push to get there has now entered the political arena, with candidates from both parties proclaiming how the EHR will drive down costs throughout the health care system (Scott, 2007).

There are many quality enhancements available to providers who use the EHR. From the standpoint of the revenue cycle, it makes sense to think about this electronic wonder toy and its effect on the non-clinical functions of health care. Some of the potential advantages of EHR are:

  • Clear, legible documentation (with spell check)
  • Templates that identify all of the critical data required
  • Physician education on utilization of EHR
  • Completed medical records
  • No paper (based on proper interfacing)
  • Improved control of internal data
  • Security in transferring data to others
  • Enhanced coding of documentation
  • Quicker turnaround of chart completion
  • No lost or misplaced records
  • Improved patient information for better care

In Access Management, some key elements have a connection with the patient’s EHR. With a “read-only” designated EHR ability, each of the sub-functions of Access Management can use the EHR in a very effective manner. If the scheduling task force had the ability to view the patient’s medical record information in a ‘read-only’ capacity, based on documentation, they could validate the reason for the patient’s admission and visit. EHR may also offer an indication as to the projected date of admission and thus establish the possible dates for pre-admit testing (Kulhanek, 2006).

The EHR contains some of the patient’s basic demographic information, and this can be validated by a phone call (or letter) to the patient. Most instances of pre-registration occur based on the data collected by Scheduling and previous patient accounting information. Since the EHR is not a financial document, minimum accessibility would be needed to complete this function (Kulhanek, 2006).

The ability to have access to the EHR is very important since the scheduling of the requested ancillary tests is in accordance with quality patient care. Again, having the ‘read-only’ access to the EHR would validate the medical necessity of the tests requested. In fact, for standing orders, the physician should provide a listing of the diagnoses associated with the tests. This coordination of information is highly valued by clinical staff.

Connected with information in the EHR, the registration staff can work with the pre-function in order to determine if the admission is a patient courtesy admission where registration welcomes the patient and reviews documents, obtains signatures, and escorts the patient to his or her next point of service, or requires some additional discussion regarding his or her financial responsibility (Walker, 2005).

Utilizing the EHR, the staff verifying the insurance has the ability to not only validate that the patient has that particular insurance (eligibility) but that the particular insurance will pay for the services to be performed (coverage). These two elements are critical in the Access Management area and in keeping the patient informed.

This is the process where patients usually find out what their third-party deductible is, what their overall coverage is, what their co-pay may be, and what other arrangements are available to resolve any outstanding debt. Usually, information from the other Access Management areas provides this function with enough knowledge to perform their tasks adequately (Walker, 2005).

In the functional area of Medical Management, there are some key elements that all have a direct or indirect connection with the patient’s EHR. Case management staff reviews the EHR for appropriate wording of medical necessity and clinical progress as well as managing patient care to assure quality and an appropriate release of the patient to the next level of service, be it home or additional post-discharge care. The case management staff should be notating the EHR as appropriate.

Concurrent coding is the active involvement of certified medical records staff to review the patient’s EHR during the inpatient stay and to assign the ICD-9 CM codes of the patient’s condition. This allows for the agreement and clarification of these codes by the physician and usually assists at the time of the discharge summary. This function of the revenue cycle is usually recognized as the physician’s primary responsibility.

It is the physician’s documentation that is coded by HIM (health information management) staff for clinical data transfer to outside agencies as well as to the patient accounting system for billing purposes. HIM staff uses the physician documentation only for coding purposes. Nursing documentation is utilized as a support for the physician’s actions in providing treatment to the patient. Physicians use the nursing data to determine the CPT code (ICD-9 Volume 3 code for inpatients). The physician’s description of the patient’s condition is usually coded as an ICD-9 CM code. All of this information must be in the EMR (Carter, 2004).

This process is the interpretation of the documentation from the patient’s EMR by the HIM staff person, certified or non-certified. The assigned codes appear on the bill form to be transmitted to the third-party insurance of the patient for payment of services rendered. For inpatient, the codes assigned are typically the ICD-9 CM diagnoses codes and ICD-9 Volume 3 surgical procedure codes; for outpatient, the codes assigned are typically the ICD-9 CM diagnoses codes and CPT-4 procedure codes. The assignment of these codes is typically called “soft coding.” These codes are usually documented in the EHR and transmitted to the patient accounting system for bill generation (Carter, 2004).

The Charge Description Master (CDM) contains the listing of all the services rendered by the hospital, clinic, or physician office that relate to a CPT-4 or HCPCS code. There is no direct connection to the EMR. The indirect connection is the fact that all services and charges generated through the CDM can be found documented in the EMR.

In-Patient Financial Services, there are some key elements that all have a direct or indirect connection with the patient’s electronic health record. The majority of the time, the initial claim generation and submission are performed electronically through the patient accounting system. This function is considered to be an automated function, and therefore there is no connection with the EMR (Wang, 2003).

The follow-up function of the revenue cycle is typically performed by staff whose main role is to contact third-party insurance companies to obtain the status of the recently submitted claim. Now, with HIPAA transactions, staff can perform this task electronically rather than by telephone, which eliminates long periods of waiting. Follow-up usually will not involve a direct connection with the EMR unless there is a potential hold on a claim due to some clinical question. If the electronic response from the HIPAA transaction indicates a potential hold on the claim, the ability to have a ‘read-only’ view of the EMR can possibly resolve the question (Wang, 2003).

Again, similar to claim generation and submission, many facilities are doing electronic payment posting with the HIPAA transaction set. This electronic process aligns the patient account numbers with the payment amounts from the remittance advice and posts the data to the host patient accounting system. There is no need for any connection to the EMR.

The denial management team will review the claims that have not received appropriate payment. If the posting is electronic, this area usually prints the zero pay accounts and gives the data to the denial management staff. If the posting is manual, the remittance is given to the staff after the posting is complete. For example, if the denial was due to medical necessity, the denial management staff can review the EHR and determine if the denial is appropriate or should be challenged.

The Appeals team typically works with inpatient claims, but there are some ambulatory surgery claims that could go to the Appeals team as well. The ability to review the clinical history of the patient pertaining to a payer denial is critical to the challenge. Typically, the ability to re-submit an inpatient clinical denial for consideration is totally based on the level of documentation found in the EMR. If the Appeals team can review the information electronically, then the decision to meet with the physician to discuss the appeal becomes much more practical and easier for both parties.

There may be more than one action associated with a claim, and in the final resolution process, all possible actions are reviewed to assure that this is the “final” action. A review of the EMR may be helpful during this process, especially if the final resolution is to write a claim off due to a clinical reason (medical necessity, lack of documentation, the diagnosis does not support test requested, etc.) This function is typically performed by a supervisor or high-ranking manager (Khosrowpour, 2003).

In fact, some physicians who do not particularly like computers now write less or abbreviate more. In an effort to reduce computer time, the HIM department may want to work with physicians to develop a standard dictionary of abbreviations so that everyone is using the same accepted language. Overzealous physicians who love computers and write abundantly and thus see fewer patients or work late updating patients’ EHR. The unauthorized construction of templates by some physicians or companies can lead to problems. Formats must be standard, and blanks need to be established with the expectation of added information to support a diagnosis, symptoms.

The EHR is just as much of a legal document as the paper record was. The EHR can be a valuable tool in the revenue cycle, and with education and training, it can add to the overall quality of care both clinically and financially. The PM system must be installed first to ensure that the front desk office staff is aware of its functions and features. The EHR system must be installed after two or three months. This allows technicians to review any technical issues and also makes sure that nothing disturbs the previous system. Vendors which install EHR systems have several plans and techniques to assist hospitals in the smooth implementation of EHR systems. Some areas include import, timing, and training.

The primary achievement of EMR is to save time. The EMR technology is quite advanced already, but because it is so recent and the development costs are so high, many of the technical assets and shortcuts are not grouped into a single product. Each is disseminated according to whatever the doctor’s specialty may be, advancements only being made when necessitated by the field. The real vision for the future of this market will take the best of each field to make one universal system (Kiel, 2002).

Doctors and nurses create electronic questionnaires for patients waiting in the examination room. Their answers are fed into the computer by the hospital staff. There are production issues with this method, but there are many advantages. Doctors must avoid filling the electronic questionnaires to avoid getting overwhelmed. Patients prefer talking to the doctor rather than answering questions on a computer. The easiest way would be to let the patients fill the questionnaires themselves. Most questionnaires have simple yes/no functions, which would also allow the patients ease in filling them out (Kiel, 2002).

Hospitals that use web-based systems for interviewing patients allow the latter access to the system. Information is processed according to the instructions. Interviews are conducted where the patient is asked queries about complaints. Further questions are asked. The system asks for further complaints, and at the end of the interviewing session, the patient records are transferred to the EMR (Kiel, 2002).

EMRs are a fact of life, but until details of ownership and transfer are thoroughly worked out, institutions need to consider certain questions and act accordingly. State and federal regulations have left a void in the management of EMRs that is being filled by contract law; lawyers always try to write contracts to benefit their clients. With a multitude of EMR providers and varieties of IT, services engaged by almost every healthcare institution, the prospect of dueling clauses and “holes” in the management of medical records is daunting.

Electronic medical records are being generated that would allow doctors of different disciplines and hospitals to interact with each other. This means that hospitals, therapists, physicians, and other providers will see what others have recorded regarding a patient’s health care. There is the need to record information in standardized, universal documentation. This means less free text and a more structured, interactive recording of specific data elements, eliminating ambiguity.

Any physician may read the documentation and may question it. Privacy concerns are bound to generate controversy. Any patient who is admitted to a mental health institution might face serious harm. The recording of admission into a mental health facility may do harm. Certain prescriptions allow others to reach a conclusion about a patient’s status. Although this was always true, the problem is magnified when a whole medical community gets access to such information (Kiel, 2002).

Medical records and their copies must be available for patients. But for professional reasons, physicians may want to communicate something to their colleagues that they don’t want to be available to the patient. Such a message could be a simple code that warns, for instance, that the patient threatened twice to sue. Many physicians are using the EMR due to its advantages. Other doctors might be thinking of switching, while others might be reluctant and hesitant to use the EMR (Kiel, 2002).

According to studies and polls conducted by researchers, at least 28 percent of doctors in the US use EMRs. An EMR system makes billing, patient history, claims, insurance, and management more efficient. However, it does have its drawbacks as it can cause losses in time, interaction with patients, and productivity. Like other emerging technologies, doctors are adjusting to the EMR (Kiel, 2002).

Patients have reported satisfaction with the EMR system. Many also express their satisfaction with those doctors who use paper records. Patients sometimes express their confusion at doctors using EMR. For instance, they find it astonishing and strange about physicians who continuously stare at monitors. Physicians who use EMRs must improve their communication skills to ensure that the patient is comfortable during a house visit (Kiel, 2002).

A computer monitor screen can negatively affect patient-doctor relationships, especially if the physician has poor communication skills. Physicians must be trained about the technical aspects of the EMR system as well as how it affects patients. Sharing this knowledge with colleagues will definitely solve the issues.

References

Scott, Tim (2007). Implementing an Electronic Medical Record System: Successes, Failures, Lessons. US: Radcliffe Publishing.

Kulhanek, Brenda J. Kulhanek (2006). Ready For The EMR: Keys to Preparing for Successful Use of the Electronic Medical Record. US: BookSurge Publishing.

Walker, James M. (2005). Implementing an Electronic Health Record System (Health Informatics). US: Springer.

Carter, Jerome (2004). Electronic Medical Records: A Guide for Clinicians and Administrators (Electronic Medical Records). US: American College of Physicians.

Wang, Sean (2003). Advances in Web-age Information Management: Second International Conference. US: Springer.

Khosrowpour, Mehdi (2003). Pitfalls and Triumphs of Information Technology Management. US: Springer.

Kiel, Joan M. (2002). Information Technology for the Practicing Physician. US: Routelege.