The idea of starting over with computerized Electronic Health Record (EHR) systems and doing them right as mentioned in my previous post has struck a resonant chord. Unfortunately designing an EHR that works may be a fantasy, due to one huge hurdle that would have to be overcome first. But it is fun to imagine an alternative universe where EHR systems were patient-centric instead of being designed to maximize patient billing. Patients ought to be central to the design of EHR systems, just as they should be the focal point of the entire healthcare system. A patient-centric EHR would also be a much easier system to use for physicians than the current billing-centric disaster we are dealing with.
The hurdle mentioned above is the tying of billing to documentation. Like the tying of health insurance to employment in the United States, this is an ill-conceived marriage. Tying billing and documentation together stems from an attempt to make the billing process as granular as possible, to the point that documenting an extra few points in the review of systems results in increased billing. This system has created a cottage industry of coding specialists, but does not seem to have any other real advantages. There are plenty of downsides. Documentation becomes a surrogate for the actual work done by the physician. And since the default assumption appears to be that if you did not document something you did not do it, physicians are constantly concerned with whether they are documenting correctly. Incorrect documentation can lead to over-billing or under-billing and even charges of criminal fraud. The rules for determining proper billing levels are complex and open to interpretation. Like the IRS tax code, medical coding is a huge mess.
A major issue with this system, apart from the neuroses it imposes on physicians trying to bill correctly, is the bloat in documentation that occurs. Current EHRs allow cut and paste and carrying forward of information from previous notes. It is easy to have a template with boiler-plate text inserted about discussion of risks and complications, even if such a thorough discussion never occurred. A few clicks and a complete review of systems appears in the chart, whether or not it was done. The result is a very detailed note, billable at a high level, that may not properly reflect anything about the actual interaction between the physician and patient. The note is large, but the signal-to-noise ratio is small.
All this stems from the present conjunction of billing and documentation necessitated by these very granular billing rules. If billing were not tied to documentation, then its only purpose would be to record information useful for the treatment of the patient. A much shorter note would suffice. The review of systems would not be repeatedly documented by every specialist who sees the patient. Nor would the family or social history, which presumably does not change very rapidly over time. If the physical exam has not changed, it would be ok to write “no change in physical exam.” There is no need to embellish such a statement, other than the current incentive to provide physical exam points for coders to calculate billing.
How could billing be decoupled from documentation? Make it less granular. Instead of 5 office E/M follow-up visit levels, just have one. Sure some visits are longer than others. But it would probably all even out over time and the savings in the cost of documentation and coding would be worth it. Same with hospital visits. One level for new visits, one for follow-up. Procedures also shouldn’t be coded so complexly. A catheter ablation would have one code, regardless of what was done during the ablation. This may strike some as unfair. You wouldn’t get extra credit for an unusually long and difficult ablation, but you also would get more than you really deserved for a nice short, easy procedure. Again the simplification of coding would, in my opinion, outweigh the disadvantages of this system. Think of this in the same way as some have approached simplifying the IRS tax code. A simple graduated tax, with no complicated exemptions or credits, would probably in the long run bring in more money, even if the tax rates were lower, because it would be less costly to apply and it would be harder to game the system.
Having uncoupled documentation from billing, documentation would only need to indicate that you made a visit or did a procedure to satisfy billing requirements. After that, documentation could resume its proper place, recording brief notes about patient progress, changes in history and physical exam, lab tests, diagnosis and treatment. Designing a useful EHR around such a paradigm would be simple. Notes could be handwritten, dictated, or typed on a mobile tablet. Patient information should be in a universal data format, accessible to any involved physician via the Internet. Cloud-based recording of drug and pharmacy data should also be universally available through the EHR interface to doctors, nurses, patients, and pharmacies. Billing would be simple. If you wrote a note on a certain day, you would be credited for a hospital visit, or office visit, or procedure.
I will leave fleshing out the details as an exercise for the reader. If we could somehow loose (and I do mean loose here, grammar nit-pickers) medical documentation from the bonds of billing, a well-designed EHR would be a joy to use.