Post on 17-Dec-2015
Preceptor: Louise A. Mawn, M.D.May 30, 2008
Medical DocumentationMedical record serves many functions
For health care providers it facilitates:Communication with other providersPreservation of informationContinuity of care
The medical record and its documentation is also used for:Billing, physician reimbursementMedicolegal issuesClinical ResearchInternal auditing and quality assurance by hospital
administration
Medical DocumentationReasons for improving documentation:
Enhance the quality of medical careImprove legibility for other providers and for
data collection (clinical research, medicolegal defense)
Optimize for billing and reimbursementReduce the time spent recording data
Many experts consider electronic health records the solution to improving documentation and quality of health care
Schriger DL, et al. JAMA. 1997;278:1585-90.Wrenn K, et al. Ann Emerg Med. 1993;22:805-12.Chaudhry, et al. Ann Intern Med. 2006;144:742-52.
Medical DocumentationStarPanel is Vanderbilt’s electronic medical
recordThe Ophthalmology Consultation Form was
implemented in the summer of 2006.
The purpose of this study is to compare the electronic medical record to the paper record to help optimize our electronic consult form.
•Compare the electronic medical record to the paper record to help optimize our electronic consult form.
• Assessment of documentation through record of billing level of service• Determining the lagtime in posting billing charges as a measure of efficiency• Evaluation of completeness of documentation by examining a specific diagnosis
MethodsRetrospective chart review
All adult and pediatric consultations performed between two twelve month periods were identified:
July 1,2005 to June 30,2006: Paper record = 1,038 consultations
September 1, 2006 to August 31, 2007: electronic medical record= 1,064 consultations
Consultations performed during the two 12-month dates of service
577
461 485
579
Dates of Service
Nu
mb
er
of
Con
sult
ati
on
s 1,038 1,064
Methods: Question 1Is there a significant difference in the level of billing
between the two groups?
The level of service to bill is determined by a specific quantitative algorithm of three categories: history, physical exam and medical decision making.This is translated into a 5-digit CPT* code (9925x).
The billing level for each consultation performed during the two 12-month periods was recorded numerically 1-5.
*Current Procedural TerminologySilfen E. Am J Emerg Med. 2006;24:664-78.
Results
Billing Codes
Nu
mb
er
of
Con
sult
ati
on
s
Frequency of Billing Codes
ResultsMean level of billing:
Leve
l of
Bil
lin
g
Methods: Question 2• Is there a significant difference in the lag
time to billing?
• Lag time: Number of days between date of service and the posting of the charge
ResultsMean lag time in billing, in days
Methods: Question 3Is there a significant difference in the quality
or completeness of documentation of consultations?
In order to answer this question, a specific diagnosis was chosen.
Wrenn K, et al. Ann Emerg Med. 1993;22:805-12.Kanegaye JT, et al. Ambul Pediatr. 2005;5:253-7.
Methods: Question 3233 consultations with a diagnosis of orbital
floor fractures in the two periods of interest were identified using the ICD*-9 codes: 802.6 and 802.7
92
26
102
13105
128
Nu
mb
er
of
Con
sult
ati
on
s
*International Classification of Disease
Methods: Question 3
Nature of injuryDiplopiaVisual acuityPupillary examMotility/Forced
Ductions
Deviation/StrabismusInfraorbital sensationOrbital Rim PalpationInterpretation of
Orbital CT scan
Based on the American Board of Ophthalmology’s Office Record Review Module on “Blowout Fracture of the Orbit”, 9 aspects of the history and physical were identified as being key elements that should be included in the medical record.
Example of a consultation recorded by free-text on paper
Example of a consultation recorded on the electronic record form
Methods: Question 3
Each consultation was reviewed and the following recorded:
The total sum of categories fulfilled in each consultation
Initials of the consultantMental status - if the patient was awake or
sedated at time of the initial consultation
ResultsMean number of categories fulfilled:
Nu
mb
er
of
cate
gori
es
ResultsThere were 21 consultants – too many to
include as a variable
Mental status:
ResultsMultivariate analysis
Awake/sedated status did have a significant effect on the number of categories fulfilled (p<0.0001)
When considering the mental status as a separate variable, the difference in the outcome of the number of categories fulfilled between the paper and electronic records did not depend on whether the patient was awake or sedated (p=0.2107)
ConclusionsHigher level of billing for consultations that were
on paper recordEMR re-examined and changes made to form
Less lag time in posting charges with implementation of EMR formImproved legibility, immediate availability of EMR
form
More complete documentation of patients with floor fractures on paper record compared to the EMR
Limitations and Recommendations for Future Studies
There were 3 coding specialists during the two 12-month periods studiedRepeat with 1 coding specialist
Completeness of the medical record only studied for a single diagnosisExamine other diagnoses
Limitations and Recommendations for Future Studies
Is the difference in billing level and lag time meaningful?Analyze the amount billed and the actual
money generated
No gold standard for measuring the quality of documentation
Acknowledgements
Thanks to:
Preceptor: Louise A. Mawn, MDStatisticians: Chun Li, PhD and Pengcheng Lu,
MS