Wednesday, February 10, 2010

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.



Bob said...

The EMR revolution, because it is anything but slowly evolving, is like the database revolution in information technology back in the 90's. Suddenly every piece of data that you could put your hands on needed to be scrubbed and added to the database (most notably at relational one) as quickly as possible. The problem two decades later is that most of the data is still not usable for what was envisioned for any number of reasons. The push in EMR is a parallel path. They need to provide tools to help clinicians get the proper data into the system, like voice recognition or God forbid returning to the days of dictation. More stick equals less quality data as I have observed in three decades of experience.

Elizabeth Han said...

I hadn't considered this facet of EMR before. Thanks for sharing! I sometimes feel this way about email and other 'efficient' technologies. I find that it is an expectation that you answer your emails right away, but at times I just need to let them sit for a while, whether to do a better job with the reply later or because there is another urgent task waiting. It's a fine balance between being connected and being a technology's slave.

rlbates said...

Nicely said, Dr Wes.

Anonymous said...

One has to pay the piper. If a MD in private practice fails to bill on time he/she starve.
Th organization suffers financially fo errant physicians. Patients and other colleagues suffer when one fails to do their charts in a timely fashion.
Excuses that EMRs impede work flow are weak, physicians control their own work flow and in our Group the most productive are also usually the most quality conscious

Anonymous said...

Dr. Wes,

Just a patient, but it's better than the old days. My husband died of cancer twelve years ago, before he was on Medicare. We had insurance but I was amazed when I was still getting hospital/doctor bills more than a year later! I had to research them because I was worried about billing errors (double billing) - a natural assumption when billed at such a late date.

aasaa said...

It's easy for bystanders to act like it's ridiculous of doctors to find this problematic because they've never had to do it. Trust me, you have no idea of the sheer volume of crap this involves. It used to be possible to set up a work flow so that you could train someone to handle the most redundant of the paperwork and ensure that you just got the necessary stuff routed to you.

Thanks to the "wonders" of EMR, nothing makes administrators happier than the ability to make you go through 40 electronic charts a day for no other reason than to ensure that all the billing documentation is in order and then sign it with your special login. It doesn't cost THEM anything to heap ridiculous amounts of paperwork on you, because the expectation is that you just get to go home later every day. Actually, I need to stop writing this post before I have a stroke.

hagbard said...


I design information systems professionally. One of the things that almost everyone doing so looses track of is 'What's in it for the poor sap providing the data'. You always have to keep that poor sap (the physician in your case) in mind and do your very best to both streamline their experience and provide some benefit directly to them that makes it worthwhile. If you fail to do that... well, let's just say you find that the timeliness and quality of your data suffers.