The Carrot and the Stick

It's an age-old problem, made more complicated by our new era of electronic medical records: optimizing collections in a time of unprecedented price pressures on our health care complex. With the economic downturn and declining government payments for services, everyone in health care is feeling the pinch.

It is no secret that work not billed will ultimately be work not paid. Hospitals and practice managers, adept at business principles, know this. Deep down inside, doctors know this, too. Historically, doctors dictated when they billed their patients, even if it meant waiting over a week to do so. If a doctor was to take a vacation, some of those billings could wait until his return.

Not so any longer.

As doctors surrender their autonomy to hospital systems with electronic medical records (EMR), more and more pressure is placed on them to complete electronic transactions in a timely fashion. Bills submitted to insurers simply must have all of the necessary data up front when submitted electronically, lest the have a high coefficient of elasticity and bounce back for revision before being paid. The EMR is incredibly savvy at tracking how many patient encounters are left open, for how long, and by whom. Daily reports are generated and performance tracked by administrators. Some doctors blend into the this computer-driven workflow naturally and are timely at completing records. Others are less so, accumulating open encounters for a period of time before sitting down to complete their documentation at a later date.

But delays in closing records has plenty of implications for patient care. For one, other providers can't see what the managing doctor's thought processes were during the patient's visit since their note does not appear "publicly" until the encounter is "closed" electronically. Tests that return before the note was completed might also be difficult to interpret based on the discussions held with the patient. Finally, there is a limit of how long Medicare or other insurers will permit claims to be submitted to assure payment for services rendered. In short, the clinical and financial log jam is significant when such delays to electronic documentation occur.

Physician and administrative leadership must assure timely documentation of patient visits and test results. To do so, a number of methods are tried, the most common being gentle reminders in person or by e-mail: a "carrot" of sorts. But when these fail, a more stern warning might be issued and if not completed, a stick can be levied not previously known to doctors: fines that must be paid on a per-open chart basis. Suddenly, documentation on a computer takes on new importance that supersedes future patient care until charts are completed. Invariably, this gets peoples' attention. In effect, the stick works.

Now if a reasonable time frame is allowed before the stick descends, even the most reticent of doctors can live with this approach. They understand the need for timely documentation. But how long should the grace period for chart completions or verifying test results be? One, three, five, seven, ten or fourteen days? Too long and finances and patient care lags. Too short, then doctors who do not reside at a computer terminal 24/7/365 will be unduly penalized for doing what they should be doing: talking to and examining patients, placing hands in and on patients, traveling between care facilities, rounding on wards or teaching students and the like. Further, if penalties are imposed after periods that are too short, the implicit (but never stated) expectation is that notes will be completed on-line after hours when the doctor is home or even on vacation.

Increasingly with financial and health care cycles shortening, it is clear that with improved "efficiencies" in health care delivery and billing practices inherent to EMR systems, increased pressure is being placed on doctors to stay connected to the EMR system - even with fines - that has little respect for physicians' personal lives or geographic location.

-Wes