FAQ 1. What is an EMR/EHR?
- An electronic medical record (EMR), or electronic health record (EHR), is a systematic collection of electronic health information about an individual patient or population. It is a record in digital format that is theoretically capable of being shared across different health care settings. Due to the stimulus package, most hospitals have moved or are moving to an EMR to satisfy the requirements.
FAQ 2. What are the advantages of an EMR?
- Implementation allows hospitals to qualify for incentive payments.
- Improved Legibility
- Alleged Faster chart completion
- Templates for common presenting complaints
- Prompts can cue you for medication allergies, medication interactions
- Macros for Review of Systems (ROS), Physical Exam (PE), Medical Decision Making (MDM)
- Macros can cue you for specific questions to ask/ exams to complete for a specific complaint
- Real time access to record for previous encounters and diagnostic studies
- Link functions allow for including past history, family history, medications and allergies into the record.
- Improved communications with other providers for continuity of care
- More accurate Evaluation and Management (E/M) coding
- Improved ease of metric reporting and real time reports
FAQ 3. What are the disadvantages/risks of an EMR?
- Faster chart completion
- Speed is not the same as efficiency, nor should it be achieved by sacrificing accuracy. The EMR should help physicians work quickly while maintaining optimal care and compliant documentation.
- Templates for common presenting complaints
- History and physical exam documentation content should be determined by the clinical circumstances of the patient as it relates to the presenting problem and not be driven solely by the template. History or exam components that are not performed should not be documented simply to complete the template.
- Macros for ROS, PE, MDM
- Macros that are inserted without editing may contain elements that were not asked or examined during the specific patient encounter. Physicians need to be certain that the medical record accurately reflects the patient encounter. Records with identical physical exams/ROS could appear to be cloned (see FAQ 4).
- Copy and paste functions allow for inserting past history family history, medications and allergies from previous records.
- Inappropriate use of the copy and paste function can cause the physician to inadvertently falsify the medical record or create an ED chart that appears to have been cloned (see FAQ 4).
- Helps optimize E/M assignments.
- More documentation does not equal a higher E/M level. E/M levels are determined by the nature of the presenting complaint, History, Physical Exam and Medical Decision Making. Evaluation and treatment must be medically necessary and appropriate. “Over documented” charts such as, documenting a 10-point ROS and a comprehensive physical exam on a patient who as an isolated ankle injury, should not result in a higher E/M level being assigned.
- Four Common Pitfalls
- Communication Errors
- Poor Data Display
- Wrong Patient/Wrong order
- Alert Fatigue
FAQ 4. Has CMS provided any guidance for documentation in the EMR?
- CMS has made no official policy regarding EMR documentation practices, but has allowed the local carriers to create their own guidelines. Published policies on copy and paste style “cloning” of information.
- “Cloning of documentation has been found on reviews of several providers. Documentation is considered cloned when each entry in the medical record for a beneficiary is worded exactly like or similar to the previous entries. Cloning also occurs when medical documentation is exactly the same from beneficiary to beneficiary.
- It would not be expected that every patient had the exact same problem, symptoms, and required the exact same treatment. Cloned documentation does not meet medical necessity requirements for coverage of services rendered due to the lack of specific, individual information.
- All documentation in the medical record should be patient specific. Cloning of documentation will be considered misrepresentation of the medical necessity requirement for coverage of services. Identification of this type of documentation will lead to denial of services for lack of medical necessity and recoupment of all overpayments made.”
- An example of a cloned chart would be a patient who returns 2 days after initial evaluation with the same complaint. Instead of obtaining a new HPI, the HPI from the previous chart is copied and pasted into the new chart.
- Linking functions that pull in PMH, SHx, or FHx should be reviewed and confirmed at each patient visit...
- Inappropriate use of macros and templates could result in documentation that is identical across several visits or across patients with the same complaint.
- If Copy and paste functions are used, there needs to be documentation that attributes the copied material to the original record.
FAQ 5. The EHR suggests a very specific diagnosis, but I’m not sure that is the correct diagnosis. What should I do?
- Most EHR’s have a searchable database of diagnoses available for use. Many have customized the most frequent ED diagnoses resulting in a limited dropdown for initial view.
- Make sure that the diagnosis you choose is appropriate to the condition/care provided during your patient encounter.
FAQ 6. What are the signature requirements for EHR’s?
- In EHRs, authentication is the security process of verifying a user’s identity with the system that authorizes the individual to access the system (e.g., the sign-on process). Authenticating is important because it assigns responsibility for an entry they create, modify, or view. Attestation, on the other hand, is the act of applying an electronic signature to the content, showing authorship and legal responsibility for a particular unit of information.
FAQ 7. Is one EHR better than another?
There are two basic types of EHR:
- Enterprise systems which are designed to offer an integrated EHR across a hospital system. These products have an ED module, although the basic design is for the enterprise, not the ED. EPIC, Cerner, Allscripts, Meditech are examples of enterprise systems.
- Boutique (often called Best of Breed) systems are specific to emergency medicine and may have some workflow and safety advantages. Examples are MedHost, T-system, Picis and Wellsoft.
- The challenge in adopting a non-enterprise system lies in developing and maintaining interfaces between the ED and other parts of the institution.
FAQ 8. Will EHR’s decrease my productivity?
- Transition from a paper charting system or from a different EHR will result in an initial decrease in productivity which will persist for at least several months. To minimize this it is important that all users of the EHR are involved in the planning and customization of the product. Having a physician champion is key, not only to help garner enthusiasm within the physician group, but also to assure that the design matches the workflow of the department. It is not recommended to use an “out of the box” EHR.
FAQ 9. Is there anything I should not do with EHR’s?
- The most important thing to avoid as mentioned in FAQ4 is to create a chart that is cloned or has the appearance of cloning.
- If using dictation or voice recognition, it is important to read over the dictation to assure that it is correct. Similarly, if you are using scribes it is essential that you check and edit their documentation prior to signing. (See ACEP Scribe FAQ for more information)
- You should not transmit any identifiable part of the EHR via phone, email, etc. unless it is encrypted and secure. Standard e-mail and mobile phones are not secure. HIPAA compliant encryption services are commercially available. It is essential to keep the record in a HIPAA compliant protected space.
The American College of Emergency Physicians (ACEP) has developed the Reimbursement & Coding FAQs and Pearls for informational purposes only. The FAQs and Pearls have been developed by sources knowledgeable in their fields, reviewed by a committee, and are intended to describe current coding practice. However, ACEP cannot guarantee that the information contained in the FAQs and Pearls is in every respect accurate, complete, or up to date. The FAQs and Pearls are provided "as is" without warranty of any kind, either express or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. Payment policies can vary from payer to payer. ACEP, its committee members, authors or editors assume no responsibility for, and expressly disclaim liability for, damages of any kind arising out of or relating to any use, non-use, interpretation of, or reliance on information contained or not contained in the FAQs and Pearls. In no event shall ACEP be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material. Specific coding or payment related issues should be directed to the payer. For information about this FAQ/ Pearl, or to provide feedback, please contact David A. McKenzie, CAE, Reimbursement Director, ACEP at (972) 550-0911, Ext. 3233 or firstname.lastname@example.org.