By Matthew Harrison, RHIA, CPC, CCP
Chief Compliance Officer
Electronic Health Records (EHR), when implemented properly, can be a big advantage for your practice. However, a poorly implemented EHR can cause significant strain on your workflow, payments, and patient care. I have been engaged in dozens of EHR transitions and have seen both successful implementations and disastrous implementations.
We should all be able to reasonably trust that our hospital or our EHR vendor each knows what they are doing, but the fact is EHR transitions are so complex and far reaching, you and those who represent your interests must be involved. Your hospital and EHR staff may be incredible, but nobody can account for what they don’t know. A successful EHR transition requires the work of administrators, software developers, clinicians, billers, and statisticians, most of whom have never done each other’s jobs, and each of whom comes to the table with his or her own priorities and expectations. A good EHR must be complete, accurate, efficient, consistent, and useful. This requires each of those parties to work in sync toward a single goal. You can achieve these traits in your EHR transition by giving careful attention to each question posed below.
What Data Points Must the EHR Capture?
In my years of participating on EHR transition teams with multiple vendors, I have never seen one capture all required elements for billing anesthesia on the first pass. If you’ve practiced anesthesia for much time at all, you should be familiar with information requests – or cases returned to the provider for more detail. If your new EHR doesn’t explicitly account for every item you’ve been asked for over the years, your coders will still have to send those cases back to you.
The list of required items is too exhaustive for this article, but includes items such as whether or not ultrasound images are retained, the various sets of times required on certain cases (FAR more than just start and stop time), and the teaching and/or medical direction requirements. You must have someone at the table who is intimately familiar with all required data points for anesthesia billing.
What are the Rules and Definitions for Each Data Point?
Just because a field in the EHR is complete doesn’t mean it is right.
Consider Time Stamps: If a CRNA clicks the button to indicate an arterial line was placed, does that indicate the CRNA placed the line because he clicked the button, or did the CRNA just click the button while the physician actually placed the line? Further, was the placement time of the line exactly when the CRNA clicked the button, or was it several minutes before or after? This single scenario of a CRNA clicking one button can cause significant confusion and potential false claims if the entire scenario isn’t understood by everyone involved.
Consider Medical Direction Attestations: Some systems allow all attestations to be completed at the beginning of the case, before some of the events even take place. Some systems allow a provider to attest to “present at emergence” even if he left the case an hour before it ended. This will look “complete” to anyone who reviews the record, but deeper analysis will uncover significant accuracy issues.
There are a number of nuances like these that must be fully understood by all involved to ensure the final record reflects what actually happened.
How Does the Provider Enter Each Data Point?
Electronic systems are supposed to enhance and improve our processes – not slow them down. Good EHRs do this well. Bad ones can add hours to your week. Macros and prompts should be used whenever possible. Macros allow a provider to take a single action (like clicking a button) to populate a string of common/standard verbiage that would otherwise have to be typed out (for instance, utilization of sterile technique, medical direction attestations, post-op pain block reasons, etc…). Prompts will “prompt” the provider to enter all applicable documentation elements before moving forward (for instance, placing provider and start/stop time for line placements). This improves the overall quality of your documentation and can drastically reduce information requests. You should always look for ways to decrease entry time and prompt providers for critical items.
Does Everyone Know the Proper Way to Enter Each Data Point?
One of the most common problems I see is where the system “technically” does exactly what it is supposed to do, but the clinicians aren’t taught how to use it correctly. A step we always perform in any transition is reviewing the final record output to ensure the billing team has all the information necessary to bill. The most common problem I see is where the sample is created by the developer who built the report (of course, the sample is perfect). But when a provider enters the same information, the report is missing critical data. The clinician places information in different places than the developer intended. While the information is technically in the record, it isn’t on the billing report. Sample cases should always be documented entirely by providers – and every provider must use the system the same way.
How are These Data Points Shared with Others Who Depend on Them?
There are two parts to this one. Part one is simply defining how other parties physically obtain the record. Part two is ensuring they receive all of it.
The most efficient means to share the record is through discreet data. This is where your EHR vendor delivers a huge file of data that is unreadable by a human into your biller’s system. This information can then be mapped into the proper fields in billing or other systems, eliminating the time and error potential of data entry. However, this only works if your EHR achieves the highest degree of completeness, accuracy, and consistency. This also requires a much higher technical resource investment to set up.
The second-best option, and typically far easier to establish initially, is a “report” or “print-out” of the anesthesia record and pertinent billing data. Most EHR vendors have a template for this already, but as noted above, these templates rarely include all required information. Your team will have to review these thoroughly and provide feedback to the development team on any needed changes.
You should strongly consider shadow charting for at least a short period. One of the biggest problems from a biller’s perspective is that we often have no way to know if something is missing in the new record. Is it missing because it didn’t apply and therefore wasn’t documented, or is it missing because the provider documented it but we can’t see it? This could have significant reimbursement ramifications if undetected.
EHR transitions are not easy, but the effort put in prior to implementation will pay huge dividends for a successful transition. The stakes are too high to allow an EHR transition to derail your schedule, your reimbursement, or your ability to care for your patients.