March 5, 2007

EMRs and the Coder
By Judy Sturgeon, CCS
For The Record
Vol. 19 No. 5 P. 8

It was with mixed emotion that coders first watched the electronic medical record (EMR) make its appearance in the healthcare industry. Now that EMRs have been utilized in various forms and stages for years, many of us still remain as conflicted as we were at its inception. We may be excited to have the advantages they provide, but we still have apprehensions about the pitfalls we encounter as payment for the ease and speed of electronic documentation.

Even the definition of an electronic health record, or electronic patient record, or EMR can be difficult to clarify. What the coder generally deals with professionally is some type of digital format of the patient’s medical chart. Some may utilize a simple scanning of the paper notes and forms into an electronic file. This can be viewed on a computer and kept on a local server as well as shared across systems. Scanning documents has issues, as does anything involving chart conversion to a new format. The original forms can be varied and physically challenging to scan into a usable digital chart. This version is generally time-consuming because the process has to be duplicated: Charting is done once manually then copied into a new digital format.

The expense of the added labor is not usually a deterrent to the coder unless the department budget for copyists eats up funds that would have been available for resources to improve coding accuracy or speed. What does affect them is the time needed to convert the paper to digital format prior to coding. A backlog of documents held for copy becomes days held for coding and billing, which in turn directly affects the financial goals for most departments that have a coding function.

When we think of a true EMR, however, the product is a digitally created document, not paper that is later converted to a digital format. The advantages to the coder with this option are alluring. Coders won’t have to virtually stand in line behind everyone who needs access to the single, physical copy of the paper chart. Everyone who needs to review the chart for current care—and the coder who is trying to complete coding and billing from the previous encounter—can access the record at the same time.

The coder may also have the capability of entering an electronic query—often by e-mail directly to the physician—for clarification of ambiguous documentation. The physician can respond by promptly adding the needed information into the patient’s record, enabling the coder to complete a chart the same day, in optimal circumstances. This process alone may cut days off the discharged-to-billed time.

Another advantage to an electronic chart is the likelihood that chronic diseases, and current medications used to treat them, will be available on all encounters, not just those for which the physician takes the time to document thoroughly. Major EMR vendors offer the capability to automatically “copy-paste” a patient’s medical history and medications from encounter to encounter. As a result, coding for complications and comorbidities for statistical data and severity-adjusted information is easier than ever. For example, this function can reduce the need to search past encounters to see why the patient is taking a specific medication then query the physician to determine whether the patient still has a specific related diagnosis and confirm the medication as continuing treatment so it can be coded and included in determining medical necessity/payment methodology for that particular patient issue.

Did anyone mention legibility? Incoming medical students have grown up with a keyboard as an extension of their hands. Typing comes as naturally to them as scrawling illegibly on paper did to the physicians of past generations. The need to type information into an electronic chart is no longer the deal breaker it was once perceived to be for physicians to accept an entire facility converting to digital charting. Coders and caregivers will get incredible relief simply by being able to read the documentation provided.

How much time is spent chasing down doctors to get clarification of the cause of anemia or whether diabetes is uncontrolled? Whether a foot ulcer is caused by peripheral vascular disease (PVD) and whether the PVD is caused by plaque or by diabetes? An electronic format can be programmed to require selection of the needed information for the caregiver to document a problem diagnosis via drop-down boxes or pop-ups that demand clarification as needed. Front-end training for the physician can still maintain the speed of documentation without sacrificing clarity and specificity of information.

In a similar vein, abbreviation use can be digitally recognized and subsequently require the physician to select the appropriate complete text for the diagnosis. No one will have to guess whether PE is pulmonary edema or pulmonary embolism—the electronic prompt can be automatic and the issue can be resolved immediately.

A scanned version of a chart may be faster to put into process than a full-blown EMR, enabling the coding department to switch from a facility-based to a home-based office in a much shorter period. For coders who benefit from that employment venue, the disadvantage of trying to read scanned handwritten documents can be compensated by the ability to code at home in their pajamas, if they are so inclined.

For either version of a digital chart, this is a major attraction to the coder as well as to the employer. Imagine having no social or political office issues to deal with daily—no thermometer wars, no struggles over control of the coffee pot, no dress code violations, no monitoring minutes on a time clock. Office operating costs plummet while employee satisfaction soars. Also, productivity typically increases for coders who opt for a home office, adding even more to the benefits of having some type of EMR.

Reviewing all the advantages and opportunities that the EMR provides can make us wonder why we ever questioned this marvel of modern medical technology. However, remember that when you think you see a light at the end of the tunnel, you must first make sure it isn’t the headlight from an oncoming train. The speed and convenience of digital medical documentation is very real, but there are hazards and cautions of which you must be aware when you embark on an electronic chart conversion.

— Judy Sturgeon, CCS, is the hospital coding senior manager at The University of Texas Medical Branch in Galveston and a contributing editor at For The Record. While her initial education was in medical technology, she has been in hospital coding and appeal management for the past 18 years.

Next month’s Coding Corner continues its look at EMRs and the coder with an examination of “the dark side of the force.”