by Stephen R. Levinson, MD, HIMSS member
“Why does opportunity usually come cleverly disguised as an unsolvable problem?”
This brilliant insight appeared as the opening challenge in a 1995 presentation by Northwestern University’s director of medical management to an audience attempting to figure out the complexities and challenges of the new managed care concept of “capitation.”
In the last several weeks, those of us immersed in the concept of Health Information Transformation (HITr, the title chosen for this blog) have experienced the bright spotlight suddenly focused on the potential for “fraud and abuse” in the coding habits of physicians using electronic health records. The sudden attention occurred only after articles exploring this issue appeared nearly simultaneously from the New York Times and the Centers for Public Integrity.
Nevertheless, even these articles were insufficient to grab the attention of the EHR vendor community and many heath IT advocates and regulators, whose laser-like focus has been almost exclusively on EHR adoption and meaningful use.
The reaction that did, however, act as a call to arms for everyone involved in HITr was the immediate and forceful response from HHS Secretary Kathleen Sibelius and U.S. Attorney General Eric Holder, who both emphasized that fraud and abuse would not be tolerated!
Therefore, let’s use this opportunity to lay a foundation for exploring the widespread implications of this current development and its opportunities to expand, improve, and evolve our current software systems into the tools envisioned by the Institute of Medicine (IOM) in its publication “Crossing the Quality Chasm.” (1)
This landmark monograph “described the implementation of electronic records as a critical first step on the journey to improving our medical system and preparing to get to the other side of a documented gap in healthcare quality. Specifically, the IOM concluded that electronic records are required to build the infrastructure for a new set of systems and tools that will promote health care advances.”(2)
Although “fraud and abuse” is the oversight terminology used by Medicare and other governmental agencies, for the sake of objectively exploring the full extent of this problem, let’s agree to use the gentler (particularly for physicians and medical organizations) but more encompassing terminology “non-compliance” for the evaluation and management documentation and coding system (aka E/M).
First, is this a physician problem (as often implied by EHR advocates) rather than a software programming issue?
There is significant evidence in the compliance literature that it is not. More importantly, even in cases of physician awareness of consistently high-coding levels, improving EHR software designs successfully addresses and eliminates the non-compliance. This “software solution” approach reflects one of the central messages of the Institute of Medicine’s earlier landmark publication, “To Err is Human.”(3):” It concluded ‘Preventing errors and improving safety for patients require a systems approach in order to modify the conditions that contribute to errors. People working in health care are among the most educated and dedicated workforce in any industry. The problem is not bad people; the problem is that the systems needs to be made safer.’ “To Err is Human” emphasizes building safer systems that minimize chances for human error. Such an effort clearly requires problem identification and implementation of superior medical processes and tools.”(4)
Is non-compliant E/M coding with the use of EHRs a new challenge?
Not at all. It has been prevalent since the late 1990s, including a 1998 publication by one of the Medicare carriers condemning “cloned documentation,” which is one of the compliance barriers central to concerns we will examine in this blog over the next several weeks and months.
There have been many more articles that could have raised these compliance concerns. This list includes:
- Many articles in 2008 on EHR documentation concerns in the Journal of AHIMA; e.g., “Documentation Bad Habits: Shortcuts in Electronic Records Pose Risk.”(5).
- A 2009 cover story in Medical Economics on “The Perfect Storm,”(6), which reported the devastating economic results of E/M compliance audits by the OIG or Medicare carriers of four practices using electronic health records, including analysis of some of the software structural deficiencies that led to these problems.
Then, why is it that the “fraud and abuse” alert in recent publications seems to come out of left field to strike our awareness?
To this observer, it has long been ironic that, while one of the primary goals of HITr has been to connect the isolated silos of clinical information in health care, the HITr universe itself is populated with informational and motivational silos.
- While software developers and health information technology advocates have focused almost exclusively on the data storage, data, retrieval, and data mining advantages of EHRs, they have most often been non-responsive to the data entry requirements of healthcare professionals (these requirements highlight usability, efficiency, E/M compliance, data integrity, and promoting the medical diagnostic process).
- Another silo of information is represented by the concerns of the compliance community, summarized above.
- Yet another set of perplexing silos seem to exist in the Department of Health and Human Services itself. While the ONC section is advocating EHR adoption, and CMS is providing the funds and criteria promoting that adoption, the Office of the Inspector General (OIG) includes auditing of non-compliant EHR documentation and E/M coding as part of its 2012 OIG work plan.
The compliance community is highly sensitive to the paradox for their physicians receiving $44,000 in incentives to purchase a certified EHR, followed by the potential for more than $150,000 in fines (see “The Perfect Storm”) from an OIG audit for using that EHR.
Thus, we come full circle to a realization that this moment in time presents us with our opportunity to engage in developing solutions to this and related “unsolvable” problems that have been simmering under the surface of HITr. We all need EHR software systems, but we also need a full range of certification criteria that ensures that these systems meet all the demands of our complex healthcare systems, as envisioned more than a decade ago by the visionary publications of the IOM.
Please share your constructive recommendations on this HITr concept. In upcoming weeks, we will be “drilling down” on the concepts introduced today, and I encourage you to share your thoughts on any related issues that we should discuss as well.
- Institute of Medicine (Committee on Quality of Health Care in America), Crossing the Quality Chasm: A New Health System for the 21st Century, Washington D.C., National Academy Press, March 2001.
- S. Levinson, Practical EHR: Electronic Record Solutions for Compliance and Quality Care, Chicago, AMA Press 2008, page xx.
- Institute of Medicine (Committee on Quality of Health Care in America), To Err is Human: Building a Safer Health System, Washington D.C., National Academy Press, November 1999.
- S. Levinson, Practical EHR: Electronic Record Solutions for Compliance and Quality Care, Chicago, AMA Press 2008, page xxii.
- Dimick, “Documentation Bad Habits: Shortcuts in Electronic Records Pose Risk,” Journal of AHIMA, June 2008, http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_038463.hcsp?dDocName=bok1_038463.
- S. Levinson, D. Grider, R. Linker, and S. Thurston, “The Perfect Storm,” Medical Economics, April 3 2009, pages 18-27, http://www.emr-simplicity.com/pdf/Article_The%20Perfect%20Storm%20Medical%20Economics%204-3-09.pdf.
Stephen R. Levinson, MD (ASA, LLC) is a HIMSS member. He is with Practical E/M in Easton, Conn.