I spent most of this weekend seeing patients and generally being crushed by surging influenza cases. Increasing family togetherness led not only to the spread of infection, but to families coming together to the urgent care for testing and treatment. When multiple groups of three or four are arriving at the front desk at the same time, it makes for a high-pressure work environment. Fortunately my staff rose to the challenge and we were able to call in some reinforcements as well.
My EHR has some fairly decent template features as far as being able to set standard defaults for physical exam findings. In reality, many influenza patients appear clinically similar, so this was a great opportunity to put those features to the test. Tired-appearing male/female in mild distress, normal eye exam, clear to yellow nasal discharge, normal oropharynx, normal ears, etc. The lung exam differs from person to person, but my template was generally accurate throughout the surge.
Unfortunately, at the end of my last shift, I had a surge that templates wouldn’t help. Four people came in within 15 minutes of closing time, all needing lacerations repaired. Every one of those patients has a unique story and unique exam, although I skipped a lot of the documentation at the time so that I could get the wounds repaired, the patients home, and my staff off the clock.
That left me this morning with charts left to complete. Although that usually doesn’t happen, it gave me a chance to reflect on how tedious some of the documentation requirements are. E&M coding requirements have been around a long time, much longer than Meaningful Use or MIPS. In looking at an era of increasing requirements and mandates, it leads one to reflect on where we might be in 10 or 20 years, or if we’ll ever get it right.
Having come out of a couple of fairly conservative training programs that were pretty good about teaching physicians how to control costs and use resources efficiently, the need to document certain exam findings and history elements in order to be paid for my services is aggravating. The requirements are higher for new patients vs. established ones. Although the information can be easy to gather (think patient history questionnaire), the requirements are often clinically irrelevant.
My training programs taught me not to order tests that weren’t going to change the management plan and not to order procedures that weren’t necessary, but E&M coding requires me to collect a host of information that may or may not be relevant. That might make sense in a continuity practice, or in the light of a second opinion consultation where every fact might contribute, but it doesn’t make sense when you are an urgent care physician with a two-year-old in front of you who split his head open on the dresser.
Meaningful Use, MIPS, PQRS, and other federal incentive programs involve data collection on steroids. Providers are so afraid of missing something and being penalized that they try to gather all the information on all the patients, much like we have been doing with E&M coding. We’ve been conditioned to this by decades of regulation, and many physicians can’t afford to say no.
In the situation of the child with the cut on his forehead, I need to know what happened, if he got knocked out, if he’s generally healthy, if he’s allergic to any medicines, if he’s ever had a reaction to local anesthetic, and whether he’s up to date on his tetanus immunization. I don’t need to know his complete family history and whether there are smokers in the home, because there is no information that can be provided that would change whether I stitch him up or not. I’m repairing his wound regardless.
Unfortunately, the EHR is configured out of fear, so this information is required to ensure we don’t miss something. Multiply this times the four patients that came in at the end of shift, and the level of tedium increases. Vendors have been so focused on making sure providers can document the federally required fields that they miss the ones we really need.
I have yet to see an EHR with a checkbox for “smell of alcohol on breath” even though that’s something we see fairly often in the ED and urgent care setting. I had to document it at least twice yesterday, one time being with the gentleman who somehow stabbed a chef’s knife into his palm but couldn’t detail how he actually got hurt. I described the wounds in narrative detail, even though a picture would have been a better way to document. But you don’t get credit for having a picture in your note — you have to have discrete data.
It’s only going to get worse as the programs get more complex. Regarding the flexibility in MIPS, providers are stymied by the large number of activities from which they can choose. Flexibility is a blessing and a curse, with many of my clients asking me to just tell them what they should do. They don’t want to look through a list of 90 different potential selections and make choices — they just want to know the path of least resistance to making sure they don’t get penalized. They want to know how they can check the box with a minimum of cost and minimum of staff effort. And of course, a minimum of risk that they’ll miss something or get penalized.
I’ve had several clients ask me about opting out of Medicare entirely. Although that seems like a solution, it may not be for everyone depending on your volume of Medicare patients. Additionally, many commercial payers follow Medicare’s lead for these sorts of things (including the above mentioned E&M coding) so opting out of Medicare doesn’t guarantee you won’t have to do it anyway.
I’ve had several discussions with clients about moving to a cash-only practice, which is becoming increasingly attractive to physicians. Given the increase in high-deductible plans and narrow networks, more patients are incurring out-of-network costs. Seeing a cash physician is more attractive when you’re paying out of your own pocket than when you’re being insulated from the cost of care by insurance.
In the end, I documented all the checkboxes because I do like being employed and don’t want a nastygram from our billers. Being rebellious and not documenting an office visit code isn’t going to be a positive career move, so I did it. I gave in just like physicians across the country have done with the expanding mess of programs.
I did my charts after I went home, like many physicians have started doing since the advent of electronic documentation and remote access. The patients were all seen, I hit a new personal record for cases in a single shift, and I also tied more stitches than I’ve ever done in a single day. But I still can’t help but wonder about a future state where data isn’t a thorn in my side.
Are you surviving influenza season? Email me.
Email Dr. Jayne.