Physician’s Coding Strategist

Electronic records simplify documentation, coding

I don’t go home at night and worry’ about coding

Not long ago, Mark Deis, MD, got a letter from an insurance company refusing to pay a bill for a patient treated for abdominal pain without more documentation for a Level 4 patient visit. Instead of spending time looking at patient records and dictating a letter as he did in the past, Deis merely called up the patient’s electronic medical record, and in a matter of seconds had a six-page printout documenting everything he did during the patient visit. The insurance representative was so impressed that she called Deis and pointed out that the documentation would have supported a Level 5 visit.

Deis is one of five pediatricians at the Cleveland Clinic’s Independence (OH) Family Health Center who pioneered a new electronic medical records system beginning in October. "The system has changed our lives in a lot of ways," he says.

About 60% to 80% of the center’s 45 doctors have made the transition to the electronic medical records system. The practice includes physicians in internal medicine, surgery, family practice, OB/GYN, pediatrics, and 25 subspecialties. "We wanted to start slow and eventually get the whole building on the system," he says.

Deis, a pediatrician with the Cleveland Clinic, estimates that he can see four to five more patients a day and stay on schedule better by using electronic medical records instead of the paper system. He no longer worries about providing enough proper documentation for payers. The system prompts him through a series of templates and even records the "no" answers. It automatically records the ICD-9 code for the diagnosis and documents the level of patient visit.

"Coding is a big concern throughout medicine. With this system, it’s so much easier to capture all of the information. I don’t go home at night and worry, hoping I documented appropriately," he says.

Adjusting to the new system was easy, says Deis. He practiced using the system for two weeks on a laptop loaned to him by the software firm. When he went live on the morning of Oct. 26, he used the new system with about half of his patients. "It was no problem to use. Since then, I’ve seen 100% of my patients on the system," he says.

Frustration with the paper chart system led the center to look at moving to an electronic medical records system. "We used to have a paper chart system, and we still do. But it was complicated because an internist or plastic surgeon might want the chart at the same time, and getting it from one place to another was complex," Deis says.

After studying products offered by several companies, the clinic chose Noteworthy, a Mayfield Heights, OH, technology firm. The firm developed the system for the Cleveland Clinic with the help of a single practitioner who used it for about a year before the Independence Family Center went on-line. The five pediatricians at the center still sit down regularly with the medical information writer and walk through changes they would like to see in the system.

Here’s how the system works: When a patient comes in for a visit, the nurse enters the reason for the visit on a template on the computer screen and then answers a series of questions designed to find out more information about the patient’s complaint. "Some of the doctors’ nurses ask all the questions. Some ask only a few and leave the rest for the doctor," Deis says.

Detailed questions automatically pop up on the screen if the answer to any question is "yes." For instance, if the patient reports having a fever, the computer will ask how long the patient has had the fever and how high the temperature has reached. "The wonderful thing from the physician perspective if that it records the no’ answers. You have a record of all those thing you never could adequately document in the past," Deis says.

There are multiple screens for every encounter. The face sheet contains ongoing data about a patient including past history, allergies, and problems. The history and physical screen has two different templates — one for a well-child visit and one for an ill-child visit. The diagnosis and decision-making screen automatically enters the ICD-9 code. If there are several ICD-9 codes for a diagnosis, the doctor selects the right one.

Physicians can create a "problem list" for each patient, which comes up on the template each time the patient comes in for a visit. For instance, when a patient comes in with an ear infection, Deis can quickly see if it’s a frequent complaint and decide whether to refer him or her to a specialist. "I can write prescriptions in the computer, order lab work, or if I want to give specific instructions to the patient, I can type notes in there and print it out," Deis says.

With the new system, patients also received a printed prescription, which is easy for the pharmacist to read. There is a computer in every examining room and at a workstation in the hallway in case the doctor wants to finish his notes after he leaves the patient. The clinic plans to eventually link the examining room computers to the billing system.

"The hardest thing about using the electronic medical record system is to make the patient feel that you’re paying attention to them and not the computer," Deis says. He usually chats with his patients about school and sports activities while he finishes making notes on the chart. The Cleveland Clinic made the decision not to re-enter all the old data on the new electronic medical record. Therefore, the physicians use both paper and electronic charts.

Deis’ subspecialty is children with developmental disabilities, a group of patients who often have multiple medical problems and make frequent visits. For these patients, Deis has entered data from the paper chart showing each problem, the day it occurred, and a synopsis of the status. This gives him a quick history on the electronic medical chart.

Deis uses the old paper records only occasionally, such as when he wants to check whether he prescribed a particular medication for a patient in the past. "Some of the doctors here are computer-phobic, and they are having a harder time," he adds.