Medicare
began to destroy communications between doctors in 1992. In that year Congress
directed Medicare to pay physicians using a fee schedule based on relative
values of work done (the resource based relative value scale or RBRVS).
Medicare decided that the contents of a doctor’s note should have all the
information (data elements) necessary to justify the payment based on RBRVS.
Since then, doctor’s notes have increasingly been designed to do just that, and
to justify the maximum level of payment for services rendered. As a result, the
part of the note used to communicate a doctor’s thinking and recommendations
has become lost in a forest of required data elements.
Notes
in the medical record have always served 4 purposes:
1.
To document
for the clinician what he/she was thinking about the case at the time of an
encounter,
2.
To be used by other clinicians to understand what the writer
was thinking,
3.
To be used by the
clinician to defend him/herself if challenged in malpractice or civil suits, i.e.
to explain what he/she was thining, and
4.
To justify and
defend charges to payors for services rendered.
Prior to 1995, the first 2 purposes
for writing notes were dominant. For example, Lawrence Weed, MD at the
University of Vermont Medical Center wrote a book called “Medical records,
medical education, and patient care”[i] to help
students organize their thoughts and make clearer decisions. It was a
groundbreaking book describing the “problem oriented medical record,’ but billing
and coding for medical services was not an issue for Dr. Weed in 1970.
In
1992, with the development of the resource based relative value scale (RBRVS), Medicare created a 5 tier
system so that doctors could bill for 5 different levels of service for an
office visit. Guidelines were then developed to help doctors choose among the
levels to get the right charge and to enable Medicare, the largest payor in the
country, to be able to audit records to determine if the level charged for a
visit was “correct.” In 1995, Medicare published the first such guidelines.
In
1997 Medicare expanded those guidelines to make them more clear for clinicians,
payors and especially auditors and coders. For each element of the
documentation a specific definition now specified exactly what needed to be
included in the provider’s note to qualify for payment. Based on the
guidelines, medical records could be audited to determine if documentation
supported the charges for an encounter.
If
a medical record audit showed that the note did not reflect sufficient
complexity to justify the charge, especially if a pattern of such errors was
noted, then the physician could be charged with fraud – essentially stealing
money from the government by billing for services that were not actually
provided. If the physician happened to work for a group or hospital, the entire
entity could be at risk for paying penalties for fraud.
With
conviction for Medicare fraud carrying significant financial penalties, proper
documentation and coding has become increasingly important, at the same time as
it has become increasingly complex. Hospitals, medical groups and medical practice
consultants all stress the importance of proper coding – first to get paid for
what you did and second to document the level of service correctly so that you cannot
be second guessed by an auditor.
All
this documentation and coding may have helped Medicare and other payors confirm
that they were paying for services actually performed, but it has forced
clinicians into an uncomfortable position as documenters rather than providers
of service. With the development of complex documentation guidelines,
professional coders and audits, doctors began to fear a Medicare audit more
than a malpractice lawsuit.
No
one involved in the guideline business, coding or auditing, assuring compliance
or billing or paying for services cares about the actual content of the medical notes. They don’t care if the
diagnosis is correct, whether the right tests are done, whether the patient is
treated with the correct treatment, or if any aspect of the patient’s care is
correct. If the document reflects the correct amount of work, the charge can be
accepted and defended.
As
a result, the entire focus of medical record documentation has turned from
communication about the diagnosis and condition of the patient into a game of
documentation to maximize income and defend billing choices for medical
practices and hospitals. An army of coders and compliance officers, auditors
and record reviewers now works to maintain the record, but only the lonely
physician cares about the patient.
In
the past, at the end of a consultation, a good internist or surgeon could
summarize a case in a brief letter so that communication could be completed.
With the advent of Medicare’s 1997 guidelines, the clinician faced a choice: create
2 notes, one as a letter to the referring doctor and one for the chart to
document the visit, or use the full note as the communication with a colleague.
Some physicians do create 2 documents, but the vast majority of physicians have
decided to create and use just one complete note to be used as a means of communication.
This satisfies the need of the coders
and auditors but buries actual clinical communication, such as the diagnosis
and plan, in an avalanche of redundant data. Hence the deterioration in
communication referred to in this essay.
The
EMR has been blamed as the cause of much of our difficulty in medical
communication, but I don’t think the EMR is to blame. The EMR is an excellent
tool to help us make sure that every element of the patient’s history and the
physician’s exam and thinking necessary for our charges are documented exactly.
In fact, by using “cut and paste” technology, some physician notes can now
include every element of a patient’s history as far back as there are elements
to include. As a result, notes get longer and longer but the part that relates
to the patient’s immediate problem remains the same – usually a short paragraph
somewhere near the end of the note. This cut and pasted note can then be used
to justify a very high level of service – look at all those data elements –
while failing miserably to communicate any coherent information.
If
many physicians are dissatisfied with the quality of medical practice today, it
may be because medical practice seems to have become nothing but a money game,
with physicians seeking to maximize their income and payors seeking to limit
that same income, all played by the rules of billing and coding created by
Medicare on the 1990s. Physicians and patients can sense the shallow quality of
the game, the lack of real meaning in medical encounters, and lament the loss
of simple direct communication that existed prior to 1995. The EMR simply makes
it easier for everyone to play the game, but it does not necessarily improve
the quality of patient care.
[i] Weed L, Medical
records, medical education, and patient care; the problem-oriented record as a
basic tool, Press of Case Western Reserve University, 1969.
