Electronic Health Records and Health Information Management

Explore the role of Electronic Health Records (EHR) in the medical billing and coding process. You’ll learn about the benefits of EHR systems, their impact on healthcare data management, and the importance of health information management. We’ll discuss the integration of EHR with coding and billing practices, helping you adapt to the modern healthcare landscape.

The EHR is the fundamental tool for patient care delivery. In most organizations, it serves as the mechanism for provider order entry, documentation, coding and billing, operational management, patient flow and patient education. The utility of the record for accomplishing these tasks is directly related to the quality of the design and the ease of use of the interface. As EHRs have developed, clinician input has too often been neglected in pursuit of a more business or technology-focused approach, often due to lack of necessary resources. Unfortunately, this lack of clinician input has created a negative perspective on the utility of the EHR for many clinicians and hides the potential of a well-designed system to enhance provider productivity, optimization of clinical care, safety, patient satisfaction and throughput. This document is intended to help establish a framework for EHR resources and best practices in the emergency department (ED). The allocation of resources to increase provider and clinician input into the EHR and health information technology (IT) systems is important and will lead to significant gains in productivity, clinical care, quality and safety. EHR Standards for Legibility and Usability EHRs can improve the legibility of charts; however, they can increase clinician documentation times and increase length of stay (LOS).1 Emergency physicians (EPs) spend as much as 65% of their time on documentation.2 Though EHRs can improve legibility, one study showed that the average LOS was increased by 6.3 minutes after implementation of a customized EHR.1 To improve EHR quality and usability, it would be incumbent upon the industry to design an electronic chart which minimizes perfunctory information (colloquially known as “boilerplate language”) and which maximizes clinically useful content. Construction of EHRs has been driven by coding and billing requirements established by the federal government and emulated by private third-party payors. Any sound healthcare enterprise, including EHR and data management, should always keep the patient at the center.3 Federal regulations that stipulate documentation requirements for coding and billing purposes displace patient care from its central importance in the medical record. Such requirements lead to over-charting, invite error through the use of standardized macros or templates, and, at worst, compromise patient care by making important information harder to locate. Furthermore, such documentation requirements contradict the behavior of our patients, many of whom consider the ED to be their first (rather than last) resort for healthcare, as well as their medical home.4 Emergency medicine, despite being a widely used resource for treatment of ambulatory care sensitive conditions (ACSCs), has been burdened with impractical documentation requirements. The consequence is the modern EHR, which seeks to satisfy federal mandates while providing appropriate clinical information. Innovation is needed to streamline the documentation of EHRs to improve their utility and minimize the work of documentation. Methods, such as voice recognition software, use of templates, and scribes have helped to offset this work. Restructuring the chart could also help. Some suggestions which have merit and should be explored in EHR development include the following: 1. Parallel charting: maintain separate charts, one for billing and coding data and the other for clinical content; intended to reduce redundant information and improve clinical information flow. 2. Move medical decision-making (MDM) to the top of the chart. 3. Restructure the MDM into a miniature patient-centered chart within the larger medical record.