When it comes to EHRs, Adele Towers, M.D., sees the good and bad. Towers serves as medical director of health information management at the University of Pittsburgh Medical Center’s Melwood hospital, a role in which she supervises coding and documentation quality efforts.
She also practices geriatrics at the Benedum Geriatric Center. At HIMSS13 in New Orleans, Towers described how UPMC’s EHR, from Cerner, has expedited physician documentation, improved note legibility and removed guesswork around orders. At the same time, the technology has spawned a multitude of notes with little meaningful information, as they contain an abundance of material cut and pasted from other notes. “You read the same note over and over,” Towers said. And in many instances, the information that coders really need to assign the proper diagnosis code is missing or unclear, leading to missed billing opportunities.
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