Special AHIMA Edition September 2013

A Cure for EHR Documentation Ailments
By Joe Weber, MS, MBA
For The Record
Vol. 25 No. 13 P. 6

When a physician practice implements an EHR, stress levels ramp up and productivity declines, profoundly diminishing both the actual and perceived value that would otherwise be experienced by having electronic access to patient data. For EHRs to attain the overall positive impact that has been promised for many years, this dynamic must be reversed and resolved.

The essential and virtually insurmountable problem is that point-and-click, codified data entry is intrinsically cumbersome for inputting something as complex as patient information. When physicians switch from dictation to the templates and pick lists that are the essence of EHRs, their time spent documenting increases dramatically, a result that can leave them disappointed and grumpy.

If physicians enter most of the clinical data during the encounter, this extends the length of the patient visit. It also diminishes eye contact, which can distress the patient, and distracts the physician from processing the information presented during the encounter, a situation that can negatively impact the quality of care. Entering data following the encounter consumes even more time and presents physicians with the formidable challenge of having to recall all pertinent clinical details.

The transcription industry has devised an interesting response to this conundrum: Let physicians continue to dictate. Run the digital voice file through a speech recognition engine in the background and provide the draft to a medical editor to correct mistakes. Then, recognizing that data—and not free text—ultimately are needed for meaningful use compliance, run the corrected draft through a natural language processing engine to extract the clinical facts and convert them to codes. Since this technology is still far from mature and totally accurate, another editor is needed to correct any coding errors.

Once that’s accomplished, the resulting controlled-vocabulary codes must be mapped to the EHR fields, a messy process at best that will require another review. However, for this task, it will be the physician who must make any necessary corrections prior to authenticating the note.

The delay, expense, and multiple opportunities for error clearly make this approach foolhardy. So what’s the answer? What documentation methodology can provide accurate EHR data in a physician-friendly, cost-effective, and quality-enhancing manner? The answer, surprisingly, lies not in technology but in people.

The Remedy Is a Revelation
Let’s remove the entire documentation burden from physicians. A highly trained, remotely located medical coordinator can perform all data entry while securely listening to the patient encounter. Data will display in real time on an iPad or a large monitor in the exam room. The physician simply needs to review and authenticate. Two-way communication between the physician and the medical coordinator ensures that any documentation uncertainties instantly can be resolved.

Additionally, the medical coordinator can manage all other aspects of the encounter, including calling a nurse to the room when indicated, making sure lab results and other clinical data are available, handling referrals, notifying physicians if an important piece of patient information is missing, performing ePrescribing, and completing the coding. The physician now can focus 100% on interacting with patients and analyzing clinical information. As a result, productivity increases and there are corresponding jumps in the quality of documentation, care, and patient satisfaction. Plus, unburdened physicians are free to enjoy practicing medicine again.

It Makes Cents
Let’s take a look at the financial value of deploying a medical coordinator. An annual cost, including salary and benefits, in the $40,000 range is reasonable for a full-time medical coordinator. Should the physician be in the clinic only part time, the coordinator would be paid hourly. Physicians in a non-EHR environment dictate approximately three minutes per patient. If each encounter lasts an average of 12 minutes, a physician who sees four patients per hour will spend 12 minutes of that hour dictating.

Once an EHR is implemented and stabilized, the time spent pointing and clicking instead of dictating may decrease patient encounters to three per hour. But imagine no time or effort needs to be allocated to documentation. Instead, a medical coordinator handles that challenging task.

Those 12 minutes of physician dictation time now can be spent seeing one additional patient per hour. At an average revenue of $70 per patient visit and 220 eight-hour clinic days per year, gross income would increase $123,200. Subtract the cost of the medical coordinator, and the annual net income totals $83,200. Even more revenue is generated when the medical coordinator scenario is compared with the three visits per hour estimate for codified data entry.
For those physicians who can’t consistently fill eight extra slots with patients, the medical coordinator could be considered a small price to pay to recapture personal time by effectively eliminating the two unrewarding hours spent each day in the clinic or at home completing arduous documentation.

Even in a macro sense, medical coordinators can have immense value. As a result of several converging factors, many experts are predicting a physician shortage in the coming years. Medical coordinators can extend physician productivity by approximately 25%, a factor almost certain to boost morale, making it more unlikely they’d retire early.

Thus far, many early adopters have been pleased with the results of working with a medical coordinator. About one year ago, Terry Turke, MD, a family practitioner in Watertown, Wisconsin, took a colleague’s advice and hired a medical coordinator. “I can tell you that I would never go back to the old way of documentation,” he says. “Prior to using a medical coordinator, I was spending one to three hours every night finishing up charts. My wife would always ask when I came home, ‘How much work do you have to do tonight?’ She has quit asking that question, as my evenings are free. Documentation is done before leaving the office.”

The prospect of facing a heavy load of Medicare patients no longer rankles Turke. “I have a lot of Medicare patients, and they are coded as red in our scheduler,” he says. “I used to dread looking at the schedule and seeing what I called a sea of red with one Medicare patient after another, most with numerous, complex problems. Accurately documenting the encounters … was a real challenge and very time consuming but not anymore.”

Who Will Staff This Profession?
Although almost anyone can become a medical coordinator, medical transcriptionists appear to be the most suitable candidates. Because of their extensive knowledge regarding medical terminology, clinical processes, and the clinical data considered relevant to physicians, transcriptionists can complete medical coordinator training in about two weeks.

Thanks to EHRs and speech recognition, transcription professionals are experiencing a precipitous drop in the demand for their services. In addition, speech recognition editors are paid much less than when they performed straight transcription. Similar to bank tellers and switchboard operators, transcriptionists are seeing their profession slowly but surely become decimated, replaced by technology. Under these circumstances, it’s not surprising that many are intrigued about a career as a medical coordinator.

By transitioning into medical coordination, transcriptionists can embark on an occupation with a brighter future that will be of great value in the EHR era.

Final Thoughts
The productivity increase provided by medical coordinators will vary by physician, depending on how much documentation time is saved and other factors. However, it’s hard to envision an EHR data-entry approach that has a higher value proposition—for physicians, patients, people who enter this new profession as well as the nation’s health care system as a whole.

— Joe Weber, MS, MBA, has more than 40 years of experience in health care, focused primarily on how intelligent clinical documentation solutions can improve quality and cost-effectiveness.