EHRs: Potential for Upcoding Errors Needs Monitoring

It has been nearly eight weeks since I looked at a paper chart in both private practice and hospital medicine. As many of you are experiencing since “meaningful use” became a part of our lexicon over the past couple of years, everyone in medicine is rushing to implement an EHR.

There are lots of good reasons to implement an EHR, not the least of which is the potential to reduce medical errors in medicine, which remain a significant risk in both inpatient and outpatient settings. The payoff for folks like me has always been the potential for improvements in speed and accuracy in the medical record. We all want to reduce the burden of documentation, which seems to consume more and more of our time as requirements mount and regulation pervades every aspect of the practice of medicine. This has been elusive, but it is my perception that we are closer to this utopia that we have ever been.

This is especially true for physician assistants, who practice medicine in physician-led teams, and have additional requirements for supervising physician chart review, that have increased the administrative burden of these teams. I’m happy to report that computerized physician order entry (CPOE) and the EHR have made this administrative burden much less over the past eight weeks.

The way that our system is set up in the hospital is that all orders of PAs are routed to the supervising physician for countersignature. Orders are valid and actionable the moment that I enter them in the system, and don’t require countersignature to be executed. The beauty of CPOE is that my physician partner can countersign all my orders with three clicks of a mouse. We now have an easily accessible “paper” trail documenting appropriate supervision, as required by state law, which is a mile wide.

I read a New York Times article today that reported on an unforeseen consequence of EHRs in the hospital setting. EHRs have resulted in higher reimbursements as EHRs ease the ability to document complex visits that provide the documentation for higher complexity when billing. Physicians, PAs, and others are finding that EHRs make it much easier to follow the rules on what constitutes what level of visit being billed, and this has resulted in more higher level codes being justified.

We have to guard against the errors that the EHR makes possible, and unfortunately, while we have reduced errors in certain areas, I’m afraid that the EHR opens another realm of errors that are not possible with a paper record.

On the one hand, our system has all kinds of interaction checks and dosage range fail-safes, which can be expected to provide more safety for inpatients that are on multiple medications. We are effortlessly collecting much more health status indicator data in both the inpatient and outpatient settings, which is increasingly important to document outcomes and drive reimbursement.

On the other hand, the ease of the EHR and the rapidity of charting from templates and macros make it easy to cause errors and carry errors forward over multiple records. Both our inpatient and outpatient EHRs allow “cloning,” that is the ability to copy previous notes to the current visit. This is a great time saver in a surgical practice, as we do and record the same things repetitively. However, you have to remain vigilant to avoid carrying forward errors, or stuff that just doesn’t make sense for the current visit.

In the balance, I’m seeing significant time savings using every aspect of the EHRs at my disposal. Some of our charts in the burn unit used to be measured in feet of paper, and now they just gather dust in the chart rack as we don’t need them anymore to do our job.

The transition to CPOE was extremely difficult for everyone at our facility, but it wasn’t as hard as I thought it was going to be. I’m seeing many of the hospitalists and specialists who round on our patients using all aspects of the EHR, including electronic progress notes. More and more members of medical staff are carrying iPads and accessing the EHR on tablet devices.

The ready availability of the EHR on portable devices and via the Internet has dramatically changed the practice of medicine, and made our team-based patient care safer and more efficient. However, the infusion of a new potential for errors requires that we all understand our EHRs and use it responsibly and expertly as we grow the penetration of information technology in the healthcare system.

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This blog was provided in partnership with the American Academy of Physician Assistants.