The other big regulatory obstacle is the billing guidelines of the Centers for Medicare and Medicaid Services (CMS), which are followed by most private insurers. The guidelines for "evaluation & management" (E&M) billing codes specify that physicians must document that they have performed a certain number of services to claim a particular coding level for the length and complexity of patient visits.
Because the amounts that doctors can charge for visits depend on these codes, EHR developers designed their products to help physicians justify their coding levels in case of an audit. This was a big selling point, especially in the early years of EHRs.
However, this approach has had some unintended consequences. First, it forces physicians to follow EHR templates of drop-down click boxes that do not necessarily reflect how they conduct encounters with patients. Second, it makes them spend too much time entering data. And third, the resulting computer-generated notes are often unreadable.
Part of the standard templates that doctors are supposed to follow, for example, is the "review of systems," which covers all of the body's physical systems. In an EHR, the review of systems may include hundreds of check boxes. Most of these are inapplicable if, for instance, a physician is setting a broken bone, notes Mark Anderson, a health IT consultant based in Montgomery, Texas.
Some EHR vendors tell physicians to simply use a macro that checks off all of the boxes as "normal" findings, he says, and then change the ones that are not normal. But when the EHR converts the structured data into text, this approach generates five pages of descriptions of the normal findings, which are irrelevant to the case.
Basch says the E&M coding guidelines must be reformed before EHRs can become truly usable. But that's unlikely to happen as long as fee for service remains the predominant method of physician reimbursement. The meaningful use program, meanwhile, has no fixed endpoint; in fact, the third stage of the program is scheduled to begin in 2017.
Documentation and notes
Doctors' biggest complaint about the EHR is that it slows them down, especially in the documentation phase. "Compared to handwriting or dictating, EHRs take doctors nine times longer to enter the data," Anderson says. "Sure, you have more information in the EHR than in paper records, but it takes more time."
Eventually, he says, natural language processing (NLP) will become good enough so that it will be able to extract most relevant concepts from dictated text and place them in structured fields. Considering that medications, diagnoses, and lab results are already coded, he notes, NLP engines have to convert only a relatively small portion of text into structured data.
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