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The Clinical Documentation Conundrum

   February 01, 2017

This refocusing, however, also calls into question the usefulness of some of what an EHR is supposedly measuring, he says. "Over the past couple of decades, we've gotten obsessed with measuring or using process metrics as opposed to outcome metrics," Erskine says. "There's actually a train collision ahead of us in about two years. We're moving away from fee-for-service as quickly as we can, all the while that we're not trying to lose our shirts in the process of doing so. However, the E&M coding and the billing practices, and the law and rules that exist today, are not going away in terms of what fee-for-service expects you to write. So you have this hybrid world where you're expected 100% of the time to do fee-for-service notes with E&M coding and all these different rules in terms of what you put in your clinical note."

Erskine says he has brought these documentation concerns to officials at CMS, but that officials there are reluctant to deemphasize process-oriented documentation in favor of outcomes-oriented documentation, in part because measuring outcomes remains an unfinished task for the industry, and because "CMS is constantly concerned, and rightly so, with fraud and abuse."

While copy-and-paste use in EHRs can serve a valuable function, misuse of copy and paste has also been an issue since EHR use became widespread. Erskine says EHR vendors such as Epic are helping to distinguish when material in the physician's note has been pasted from some other source through use of differently colored or italicized fonts with such text. "It helps illuminate a little bit where people have overused or where there isn't really that much new information, which in the previous iterations you couldn't really tell," he says.

Yet another challenge is getting physicians to impose self-discipline on the length of various aspects of the documentation. "Problem lists get larger but tend not to get smaller," he says. "People have a tendency not to curate it and make sure it's nice and organized in a way that highlights the relevant things. Part of that is because, who really owns the problem list when it has 40 problems on it?"

Chances are difficulties such as this will require the joint efforts of healthcare organizations, physicians, and in particular, technology suppliers such as EHR vendors, Erskine says. "They're really trying to be ambassadors and reconcile and adjudicate those regulatory needs with what the clinicians are really asking for, and trying to do that in as elegant a way as possible, but it's going to be tough to do."

Scott Mace is the former senior technology editor for HealthLeaders Media. He is now the senior editor, custom content at H3.Group.

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