Monday, February 15, 2010
Your Doctor Will Now Be Fined For Putting Time With You Above Time With Your Chart
This post by Westby Fisher, MD, originally appeared at Better Health.
It's an age-old problem, made more complicated by our new era of electronic medical records: optimizing collections in a time of unprecedented price pressures on our health care complex. With the economic downturn and declining government payments for services, everyone in health care is feeling the pinch.
It is no secret that work not billed will ultimately be work not paid. Hospitals and practice managers, adept at business principles, know this. Deep down inside, doctors know this, too. Historically, doctors dictated when they billed their patients, even if it meant waiting over a week to do so. If a doctor was to take a vacation, some of those billings could wait until his return.
Not so any longer.
As doctors surrender their autonomy to hospital systems with electronic medical records (EMR), more and more pressure is placed on them to complete electronic transactions in a timely fashion. Bills submitted to insurers simply must have all of the necessary data up front when submitted electronically, lest they have a high coefficient of elasticity and bounce back for revision before being paid. The EMR is incredibly savvy at tracking how many patient encounters are left open, for how long, and by whom. Daily reports are generated and performance tracked by administrators. Some doctors blend into this computer-driven workflow naturally and are timely at completing records. Others are less so, accumulating open encounters for a period of time before sitting down to complete their documentation at a later date.
But delays in closing records have plenty of implications for patient care. For one, other providers can't see what the managing doctor's thought processes were during the patient's visit since their note does not appear "publicly" until the encounter is "closed" electronically. Tests that return before the note was completed might also be difficult to interpret based on the discussions held with the patient. Finally, there is a limit of how long Medicare or other insurers will permit claims to be submitted to assure payment for services rendered. In short, the clinical and financial log jam is significant when such delays to electronic documentation occur.
Physician and administrative leadership must assure timely documentation of patient visits and test results. To do so, a number of methods are tried, the most common being gentle reminders in person or by e-mail: a "carrot" of sorts. But when these fail, a more stern warning might be issued and if not completed, a stick can be levied not previously known to doctors: fines that must be paid on a per-open chart basis. Suddenly, documentation on a computer takes on new importance that supersedes future patient care until charts are completed. Invariably, this gets peoples' attention. In effect, the stick works.
Now if a reasonable time frame is allowed before the stick descends, even the most reticent of doctors can live with this approach. They understand the need for timely documentation. But how long should the grace period for chart completions or verifying test results be? One, three, five, seven, 10 or 14 days? Too long and finances and patient care lags. Too short, then doctors who do not reside at a computer terminal 24/7/365 will be unduly penalized for doing what they should be doing: talking to and examining patients, placing hands in and on patients, traveling between care facilities, rounding on wards or teaching students and the like. Further, if penalties are imposed after periods that are too short, the implicit (but never stated) expectation is that notes will be completed on-line after hours when the doctor is home or even on vacation.
Increasingly with financial and health care cycles shortening, it is clear that with improved "efficiencies" in health care delivery and billing practices inherent to EMR systems, increased pressure is being placed on doctors to stay connected to the EMR system--even with fines--that has little respect for physicians' personal lives or geographic location.
This post originally appeared on Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.
Labels: billing and coding, electronic medical records, guest post
posted by the Better Health network at
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Members of the American College of Physicians contribute posts from their own sites to ACP Internist and ACP Hospitalist. Contributors include:
Albert Fuchs, MD
Albert Fuchs, MD, FACP,
graduated from the University of California, Los Angeles School of
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Certified by the American Board of Internal Medicine, Dr. Fuchs
spent three years as a full-time faculty member at UCLA School of
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David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned
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DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about
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Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more
than a decade and is an Associate Professor of Medicine at an
academic medical center on the East Coast. His time is split
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Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science,
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FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the
Internal Medicine Residency and Assistant Dean of Scholarship &
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John H. Schumann, MD, FACP, provides transparency on the workings
of medical practice and the complexities of hospital care,
illuminates the emotional and cognitive aspects of caregiving and
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physician, and offers behind-the-scenes portraits of hospital
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Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the
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I'm dok
ACP Member Mike Aref, MD, PhD, ACP Member, is an academic
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testing using novel bedside imaging modalities, diagnostic
reasoning, medical informatics, new medical education modalities,
pre-code/code management, palliative care, patient-physician
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Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.
KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites
for influential health commentary.
MD
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Michael Kirsch, MD, FACP, addresses the joys and challenges of
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relationship, medical ethics and measuring medical quality. When
he's not writing, he's performing colonoscopies.
Medical
Lessons
Elaine Schattner, MD, ACP Member, shares her ideas on education,
ethics in medicine, health care news and culture. Her views on
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patients, as a researcher in cancer immunology, and as a patient
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David M. Sack, MD, FACP, practices general gastroenterology at a
small community hospital in Connecticut. His blog is a series of
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medical ethics, in no particular order.
Reflections
of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being
a doctor in a community hospital in Atlanta.
Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in
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evidence-based medicine tools, personal information and knowledge
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White Coat Underground
Peter A. Lipson, MD, ACP Member, is a practicing internist and
teaching physician in Southeast Michigan. The blog, which has been
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ACP Internist and ACP Hospitalist also contribute to and draw upon content from Get Better Health, a network created by Val Jones, MD, to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the clinician's point of view on health care reform, science, research and patient care.
Other blogs of note:
American
Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine
publishes original clinical articles of interest to physicians in
internal medicine and its subspecialities, both in academia and
community-based practice.
Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP
Member, associate program director at New York University Medical
Center's internal medicine residency program. Faculty, residents
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db's Medical
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Robert M. Centor, MD, FACP, contributes short essays contemplating
medicine and the health care system.
Interact
MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so
he can create an independent, clinician-reviewed space on the
Internet for physicians to report and comment on the medical news
of the day.
PLoS
Blog
The Public Library of Science's open access materials include a
blog.
White Coat Rants
One of the most popular anonymous blogs written by an emergency
room physician.
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