Selecting the proper EHR

Feb. 1, 2011

Arthur Gasch

Bill Andrews

It's amazing the amount of work the federal government can create for everyone else in just a few short months. They are like the big gear in a gear box; they rotate a little at the top, and hundreds of thousands of small IT wheels in healthcare providers around the country spin and spin and spin. With Medicare cuts, the adoption of electronic health records (EHRs), new HIPAA 5010 regulations, the transition from ICD-9 to ICD-10 coding, and the spin out of accountable care organizations (ACOs) thrown in for good measure, what are healthcare IT departments to address first?

EHRs have a deadline of October 2011 — at least that's when the deadline starts for some attending physicians.

Conversion to ICD-10 is a bit muddier. On Sept. 30, 2013, you can still use ICD-9, but on Oct. 1, 2013, every healthcare bill for every patient in the United States must have ICD-10 codes. That affects every skilled nursing facility, every homecare agency, about 400,000 physician group practices, and nearly 6,000 hospitals or other institutional healthcare providers — many of which are small organizations that lack sufficient IT staff and have limited resources to fundamentally transform today's business.

While the deployment deadline may seem like a long way off, it isn't, and it affects everyone (not just primary care physicians and hospitals), so you need to start now. In the physician setting, that means taking into account your EHR's ICD-9 and ICD-10 coding functionality. In the hospital setting, it means instituting clinical documentation improvement (CDI) expert computer systems, preferably Web based.

For ICD-10 to work and providers to get paid adequately, providers will need to be more involved and aware of how their documentation affects downstream coding. It's no longer acceptable to think of coding as the last step (after the patient is gone); the physician needs to become a more proactive part of the documentation/coding process. That means that any EHR needs an integrated E&M guide and the ability to associate ICD, CPT and HCPCS codes automatically, based on the charting (problem list, data being entered, lab orders and results, drugs and so on), so that you don't miss and end up down-coding your patient encounter when it is billed. You certainly don't want to up-code either, as this will invite RAC audits, and they can be expensive if you haven't gotten the coding right. If the EHR meets your other needs, but is weak in the coding area, adjunct CDI solutions may be an answer.

Many physicians like to dictate patient encounters. There is a solution available to you also. Medicomp's new Clinitalk provides automatic transcription using speech recognition and natural language processing to provide a coded output along with the dictated narrative. We've seen it, and it's impressive. The notes created maintain the true narrative, but out comes structured data as well, which is coded. So if you dictate, this is the approach for you. Medicomp currently has 12 OEMs — companies such as Sage Software, AthenaHealth and others — and a subset of these will be adopting the Clinitalk infrastructure. Contact David Lareau at Medicomp for details on specific companies or dates when these products will go live.

With about 13,000 ICD-9 codes to 120,000 ICD-10 codes, and about 11,000 to 73,000 procedure (CPT) codes, the scope of the paradigm change is significant. Organizations that have gotten by doing retrospective coding will need to rethink that strategy. For many individual ICD-9 codes there are multiple ICD-10 codes that apply, depending upon co-morbidities, complications, history, physical and medical decision making involved, that affect payments made for work done. Charting that inaccurately lists only basic problems that don't reflect complication and co-morbidities may lead to a net drop in income (on top of a reduced overall CMD payment schedule).

In summary, start your research on CDI and EHR now, and be sure to take into account both front-end E&M coding and back-end CDI support in whatever product (or combination of products) you choose in implementing both your EHR and your new, real-time CDI computer-assisted solutions. If you work in an ED or OR setting, be aware of the ASA codes also. Web-based tools, such as those mentioned in this article, will keep you level while you ride the big wheels of change in meaningful use, HIPAA 5010 and ICD-10 conversion into the future.

What follows is a basic and very limited summary of some of the 680 features we track on the MSP EHR Selector for various EHR companies. You will find more information at

Arthur Gasch and Bill Andrew are founder and executive VP, respectively, of MSP.

Arthur Gasch is founder and Bill Andrew is executive vice president of Medical
Strategic Planning.
For more information on Medical Strategic
Planning solutions:

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