Medical record keeping used to be simple.
I was born in the early 1960’s and saw my pediatrician for regular checkups and common illnesses until going to college in 1980. The first 18 years of my medical care were completely summarized on five 5 X 7 notecards contained in a manila packet. Each of my visits was documented by a 1 to 5 line handwritten note. There were no wasted words. My pediatrician also set the standard for illegible doctor’s handwriting!
How could my pediatrician get away with such a thing? In those days medical records served only one purpose: they were the physician’s personal notes taken to assist him or her in future care. The only outside request for my medical records was made to show I had my immunizations.
Things began to change in 1966 when the American Medical Association created Current Procedural Terminology codes, or CPT codes. The original set of codes addressed medical procedures only and did not include office visits. A physician’s bill to an insurance company for an office visit instead contained a narrative of the patient’s symptoms and the care that was given.
Over the next three decades events conspired to make medical records far more complex. The emergence of comprehensive health insurance, including Medicare and Medicaid, separated the consumer of health services (the patient) from the payor of health services (the insurer). Because the payor for health services no longer directly witnessed the patient encounter, the medical record became a necessary instrument of proof that service was delivered. A single phrase record such as “severe tonsillitis” no longer sufficed. CPT was revised to include codes that covered office visits ranging from simple level 1 visits to complex level 5 visits. Each level specified a set of documentation criteria that medical notes had to meet in order for the doctor to bill at that level.
Then medical liability was created. The medical malpractice lawsuit, once considered inconceivable, became commonplace. Physicians were compelled to add even greater detail to their medical records in order to defend themselves against potential accusations of inadequate care. In training I was taught, “if you didn’t document it, you didn’t do it.” Thus defensive medicine and defensive record keeping was born.
Next came managed care. Under the guise of cost control insurers came up with a variety of tricks in order to delay and decrease payments to physicians. One of the most popular games was to use the minutia of CPT coding requirements as a means to reduce and/or deny payments. A physician can spend 45 minutes working up a complex, very ill patient, compose an extensive clinic note, and have payment denied because the “review of systems” in the note was technically (but not clinically) inadequate. In more recent times CPT coding and the supporting medical record documentation have become so complicated that an entire industry has formed for the sole purpose of understanding CPT coding and training / certifying individuals in this new body of knowledge.
Another popular managed-care technique, still in use today, is pre-certification. In most insurance plans a surgeon cannot expect to be paid for an operation unless he gets prior approval from the insurer prior to performing the procedure. Pre-certification is often not given unless the medical record documents the need for the procedure. This puts yet another burden on the medical record.
Finally, we have the ever-increasing threat of practice audits coming mostly from the federal Office of the Inspector General. An audit includes an exhaustive review of the physician’s billings to Medicare and a comparison of those billings to the corresponding medical records to be sure the records support the level of billing. Even the most conscientious physician fears the OIG audit, knowing that even the best documentation occasionally fails to meet the minutia of CPT coding requirements. In some states these audits are now being performed by privately contracted firms (called recovery audit contractors or RAC’s) that are incentivized to find problems and levy fines. RAC auditors are not held accountable for their actions.
The future promises further obligations on medical record keeping. Pay for performance, benchmarking, outcomes research and other similar plans will raise the bar even higher.
What began in the mid-20th century as simple professional note keeping has grown into a regulatory and liability behemoth, creating a burdensome obligation for the 21st century physician. The medical record serves not only as the provider’s reference but also as documentation of service, support for billing, support of proposed future care, defense against lawsuits and as a data capture instrument for outcomes research and future pay for performance initiatives. The medical record must often face hostile audiences such has malpractice attorneys seeking liability or managed care providers looking for reasons to deny payment to the physician. With the possible exception of RAC audits I don’t regard any of the above concepts as inappropriate. But they do make record keeping much more difficult.
Into this complex and rapidly changing environment comes the electronic medical record (EMR), trying to hit a poorly defined, rapidly moving target. And EMRs have additional hurdles made just for them, including CCHIT certification and the ever changing / growing “meaningful use” criteria.
In the next post I will review how the regulatory burdens on medical record keeping distract the EMR from its best, most noble goals: improving efficiency, lowering costs and improving quality of care.
Thanks for your time and interest. Comments and corrections are welcome.
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