Bell Curve Tolls For Practice
Health Data Management Magazine, January 1, 2008
Siouxland Women's Health Care P.C. has logged a number of benefits from using an electronic health record, and one of the most important has been creating a bell curve.
When the four-physician, Sioux City, Iowa-based obstetrics practice used paper charts to document and code encounters, its Evaluation and Management codes were near the bottom of the scale. E&M Codes are modifiers to CPT codes that indicate the complexity of the case on a scale of 1 to 5. The higher the code the more the practice gets paid.
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In its paper world, the practice's average E&M Code for an encounter was about a 2, says Julie Barto, clinic administrator at Siouxland.
Payer organizations expect a practice's charges to resemble a bell curve, with most procedural coding being around a 3 and fewer charges being billed at 1 and 5, Barto says.
Having an unbalanced charge curve typically raises a red flag at a payer, which can in turn trigger an audit. It also means that practices coding too low are leaving money on the table, Barto says. "There's a couple of hundred dollars different between the low-end codes and the higher ones," she notes.
Since implementing an integrated EHR and practice management system from Atlanta-based MedcomSoft Corp. three years ago, Siouxland has increased its average coding level and made it easier to collect the data necessary to support billing codes it submits. It's also cut the costs of malpractice insurance by $8,000 annually because the practice's carrier, Minneapolis-based Midwest Medical Insurance Co., offers discounts for EHR use because it believes the software can help reduce the number of medical errors, Barto says.
During the documentation process, the MedcomSoft application is working behind the scenes: the software uses embedded business intelligence to automatically calculate the proper E&M code based on the physician's clinical notes. Physicians or administrative staff can perform manual coding overrides as needed. The system also provides prompts that enable doctors to know what needs to be done to ensure that the highest reimbursement levels are achieved.
But Siouxland's drive toward better documentation and more efficient workflow wasn't limited to purchasing software.
The practice also installed a wireless network and got physicians and other caregivers to use Tablet PCs or laptops to increase workflow efficiency.
Old paper records have been scanned into the EHR using MedcomSoft's document management system. Any new paper the practice receives, such as referrals or notes from other physicians, are scanned into the system as well.
The software is hosted by the vendor via the application service provider computing model and accessed by Siouxland through a secure Web connection. Physicians also can remotely access the application.
"If someone called and needed a medication refill and I needed more information, I would have to drive to the practice," says Mary Schneider, M.D., a partner at Siouxland. "Now all I need is Web access. I was on a vacation cruise, for example, and was able to check on patients using while on board."
Ready To Roll
The practice's staff starts using the EHR/practice management system when a patient walks in the door. New patients have their insurance cards scanned and provide demographic data that's entered into the software. They also have their picture taken in the waiting room, and the digital file is embedded into their electronic record.
Having photos stored in the EHR has proven extremely valuable during remote sessions, says Kevin Hamburger, M.D., a partner at Siouxland. "It jogs my memory and reminds who the patient is," he says.
After a patient is checked in, an electronic notice is sent to a nurse alerting them that the patient is ready to be seen. Nurses use Tablet PCs to enter vital signs and recent medical history into the EHR.
In addition, the EHR application provides additional tools at the point of care. Carole Dwyer, R.N., a nurse practitioner at Siouxland, uses a decision support application within the EHR that alerts her if additional tests need to be performed. If, for example, she documents a breast lump during an examination, the software will direct her to ask about other symptoms and alert physicians if additional tests need to be ordered.
The result is that when a physician enters the encounter room, they have up-to-date information that enables them to jump right into the patient exam, Hamburger says. "I can come in knowing what I need to ask and why they're there," he says.
Documenting On The Fly
During patient encounters Hamburger uses customized templates he designed. He uses pull-down menus to document and also enters some free text using the stylus on the Tablet PC during the encounter. If he needs to write longer notes he'll dock the computer in his office and use a full-sized keyboard.
Before the patient leaves the practice, Hamburger will have printed any necessary information the patient might need, such as educational materials. Prescriptions and referrals can be sent electronically or printed and faxed, he says.
Schneider, for her part, often uses her convertible laptop, a device that can be used as both a Tablet and laptop, in laptop mode because she enters a lot of free text during patient encounters. "I'm a wordy doctor," she says, and deals with complex cases that require more detailed documentation.
The practice decided to use wireless devices in exam rooms to maximize interaction between caregivers and patients. "We didn't want desktop computers in each room because we thought the doctor would lose eye contact with the patient and it would be too impersonal," says Barto, the administrator.
The EHR/practice management system also will enable Siouxland to collect data for pay-for-performance programs that it sees looming on the horizon, Barto says. As soon as the Centers for Medicare & Medicaid Services releases the metrics for obstetrics it will start collecting data, she says.
And the CMS standards may just be a baseline for what types of data sets commercial payer organizations will require for participation in their P4P programs, says Brian Bullock, senior manager at Healthia Consulting. Practices likely will have to track different P4P metrics depending on who's paying the bill.
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