CHICAGO -- Electronic health record implementation, and how it could affect health care reimbursements and overall costs, was a national story in the days leading up to and following the AHIMA 2012 Convention and Exhibit.
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First, a New York Times feature suggested electronic health records (EHRs) could be used for "upcoding" or "overcoding" procedures. Then U.S. Attorney General Eric Holder and HHS Secretary Kathleen Sebelius sent a warning letter to hospitals that EHR-aided fraud and abuse would not be tolerated. Finally, U.S. House committee leaders urged Sebelius to suspend the EHR implementation incentive program until meaningful use stage 2 regulations are given more teeth.
While Sebelius did not say whether her warning about upcoding was in response to the Times piece, it sure looked like it to AHIMA 2012 attendees. "It was quick," said Juergen Fritsch, chief scientist for speech recognition vendor M*Modal Inc. "Surprisingly quick."
Michelle Dougherty, director of research and development for the association's AHIMA Foundation research arm, said most clinical documentation improvement systems help boost the accuracy of care records. They check for many aspects of care that EHRs don't, such as the presence of a physician (as opposed to other care providers) during an episode of care, and remind clinicians to add certain details to the record to support the use of particular codes.
But a few of these tools can also negatively affect coding, especially when they are template-based or tempt physicians to otherwise auto-fill notes. "Some technology tools may cross the line, in terms of some of the efficiencies they're creating, that could pose a compliance problem for some organizations," Dougherty said, adding that part of the problem is payers haven't yet made clear where that line is; the market for these tools is maturing but still, as she put it, is a "Wild West."
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"There hasn't necessarily been guidance on documentation requirements coming from payers that would provide some parameters on how their systems might function to support efficiency in documenting [care that doesn't] cross the line," Dougherty said.
EHRs and the yin and yang of coding systems
Against the backdrop of these political storm clouds, health information managers pushed forward with their EHR implementations and with transitioning to the ICD-10 coding system. While the country focuses on reducing health care costs, these health IT technologies can create more accurate billing and coding and increase reimbursements to health care providers, interviewees told SearchHealthIT.
But they also said that providers for years have been deliberately "downcoding" or "undercoding," which results in a lower reimbursement than appropriate coding would but keeps the heat off hospitals from fraud and abuse investigators from the Centers for Medicare & Medicaid Services (CMS).
Pam Wirthdivision president, Amphion Medical Solutions
"I'm sure people are still undercoding," despite EHR technology that would help support more accurate coding of care, said Pam Wirth, president of the coding, compliance and quality division at Amphion Medical Solutions LLC, a provider of transcription and ICD-10 education services. "People are so concerned that they're going to overcode that they undercode."
M*Modal's Fritsch said Sebelius' warning about upcoding probably helped his company, because it drove nervous health information managers to approach it through their IT department leaders. When CMS promises deeper scrutiny on coding practices, he said, it increases demand for speech recognition and clinical documentation tools and any other technology that can strengthen the digital evidence for using a particular code to bill a diagnosis or episode of care. Vendors who develop systems that move away from individualizing each health record and promote cut-and-paste templates, he presumes, could be hurt from the media attention brought upon physicians, EHR systems and the coders with whom they work.
Meaningful use still potentially meaningful
Despite the recent beatings EHR systems have taken in the press -- being fingered as the cause of rising health costs -- Nuance Communications Inc. Chief Medical Information Officer Nick van Terheyden believes eventually these systems will be the tool to reduce costs, even when the higher costs of appropriate coding are taken into account.
"Our overall intent is that we want to improve the quality of care, manage the costs and reduce the overall total, and get the most value," van Terheyden said. "To do that, you want the best possible information. Electronic health records contribute to that."
Nuance, which provides speech-recognition and natural-language processing software to aid back-end health care coding and analytics for physician documentation, is motoring full speed ahead on developing technologies to augment EHR use in U.S. health care. The recent flap over EHRs and coding didn't stop Nuance from acquiring its fifth company so far in 2012, clinical documentation improvement vendor J.A. Thomas and Associates. That followed on the heels of Nuance's acquisition of Quantim, QuadraMed Corp.'s health information management division.
Problem lists are an EHR implementation problem
Angela Carmichael, assistant vice president of coding and auditing for Pyramid Healthcare Solutions Inc., said yes, EHR systems offer physicians opportunities to create better documentation, and ICD-10 takes advantage of that. Accuracy in these transactions, despite the negative headlines in mass media news outlets, isn't a bad thing. Sometimes, though, when physicians don't update a patient's problem list to reflect conditions they no longer have -- that is, it's simple to roll over a year's worth of visits from one set of care documentation to the next -- she said EHR systems can inadvertently contribute to the problem. But those issues can be rectified with better training, she added.
"I know CMS doesn't want to believe this, but hospitals are underpaid far more than they're overpaid," Carmichael said. "[With EHR systems and ICD-10] we're telling the story that better supports the codes we're assigning."