As a physician reviewer for Washington & West, a denials and appeal management firm, my job is to examine medical records closely for documentation that will help me write a strong appeal letter. In so doing, I have the opportunity to see medical records from many different hospitals across the country.
Specifically, I am looking for the documentation that supports the need for admission to acute inpatient care and the need for this level of service throughout the length of stay. But more and more I'm finding problems that are unique to electronic documentation, and it appears that some of these problems may have caused the denial in the first place.
Certainly, a poor EHR makes recovery a whole lot harder for our hospital clients.
Here are some examples of problems I see with EMR:
1. Information entered under "history of present illness" often merely is cut and pasted into the "course in hospital" for the discharge summary.
2. Clinical staff appears to overutilize the cut-and-paste function, which is not convincing documentation of the patient ‘s condition and often leads to erroneous and conflicting information.
3. Numerous pages of records contain needless detail, thereby obscuring meaningful information that could support medical necessity.
4. Design of the EHR often does not provide an understanding of the continuity of care from day to day. or the reasons why continuing care is necessary.
The migration to full health information management systems is a fact of life, and I support it. But it's a double-edged sword that can work for - or against - a hospital that wishes to prevent denials for lack of medical necessity or insufficient documentation to support the level of care. After all, a Medicare or Medicaid audit reviewer, or a commercial payer reviewer, is not going to spend hours going through pages of information to try to figure out the justification for the admission. I suspect that payer auditors spend a limited amount of time reviewing a medical record, so if the needed information is not found easily, a denial will result.
Nevertheless, the pros of electronic medical records are significant:
- Notes, orders, etc. are legible.
- Providers can write notes rapidly and in a standardized fashion.
- Several departments can have simultaneous access to records.
- Reminders can guide decision-making and improve patient safety.
But the cons are also considerable:
- If notes are "cut and pasted" from one day to the next, and not updated or proofread carefully, they can contain conflicting information.
- Sifting through volumes of standardized notes is numbing. Important new information, such as a problem that requires acute evaluation, does not stand out.
- A lot of data in boxes is not helpful to prevent a denial or to support an appeal. However, a clearly written assessment of the patient's problems and a justification for specific plans is extremely valuable, if seldom seen in an EHR. We want to show that the provider made a decision to keep the patient hospitalized and that the physician clearly documented the reason for that decision.
So, what can be done? First, having an up-to-date and flexible information systems department and a savvy chief information officer in place will be key to the unprecedented evolution of hospital information systems being driven by new federal regulations requiring "meaningful use" of EHR's. These departments should:
- look for certified EHRs that are efficient, adaptable and user-friendly, not only for data entry but also for data retrieval and analysis
- encourage nurse and physician use of free text options to avoid meaningless, repetitive boiler-plate information
- develop an on-site interdisciplinary team to teach how to use the system and respond 24/7 to user needs
- allow appropriate online access to medical records by HIPAA-compliant business partners that perform denial management functions
- Emphasize to professional staff that they play a key role in ensuring that claims will be paid by clearly documenting and justifying their patient care decisions.
It comes down to this: electronic or not, a medical record is only as useful as the information it contains and its ability to communicate that information efficiently. Meaningful quality of a record's information, and not quantity, will lead to better patient care and denial prevention.
About the Author
Cynthia M. Lipsitz, MD, MPH is a senior medical reviewer with Washington & West, LLC, an appeals and denials management company. In this capacity she maintains familiarity with current standards of medical care, Medicare and private-payer hospitalization criteria, and coverage policies. Dr. Lipsitz has reviewed records and observed documentation patterns from a variety of hospitals across the country, and has a heightened understanding of issues that lead to denials. With more than 25 years of experience in ambulatory and hospital medicine, public health administration, and health promotion software development, she brings an understanding of the realities of medical practice and administration to the field of denials management.
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