Andrew Coates: Scribbling In The Chart
William Faulkner, the great American writer who was born in New Albany, Mississippi, wrote screenplays to support his family, although he didn't really like the job, and referred to it as "mere scribbling."
There is a story that when the Warner Brothers Studio office, where Faulkner wrote, was cleaned out, his desk contained an empty bottle and yellow pad upon which, 500 times, he had written the words: "Boy Meets Girl. Boy Meets Girl. Boy Meets Girl."
When it comes to healthcare, many physicians might leave an echo of Faulkner's scrawl in their desk drawer. It might read: "Coding and billing. Coding and billing. Coding and billing."
Coding refers to selecting a five-digit code that labels an encounter with a patient, the code that will be sent on to an insurance company, or Medicare, or Medicaid, for payment. Billing refers to sending a claim to an insurer, electronically these days, for payment in a timely and efficient manner. Coding and billing depend upon what the doctor has written in the chart.
The idea of the medical chart might be that it should form a repository for in-the-moment descriptions of a patient's history, clinical condition, and course. The chart serves the patient by communicating information vital to the patient's future care.
One of my senior colleagues the other day stressed the value of narrative description in her charts. She believes that communicating a sense of her patient as a person remains essential to participating in the effort to become or stay healthy.
Accurate medical records are also the responsibility of every medical professional, with ethical and legal implications. A humane narrative may offer every element needed for future medical decision-making, and yet lack mention of one or two elements needed to justify a particular visit code.
I have heard healthcare administrators refer to this situation as "Money left on the table." In order for an institution to collect the money "left on the table" administrators will try to get the doctors to recored key details in order to justify "accurate" or "appropriate" coding and billing.
Last year the New York Times looked at the implementation of electronic health records in this connection. At a Utica emergency room, following the implementation of an electronic health record, the proportion of patients who were coded as requiring the highest level of care rose 43 percent. After implementation of an electronic health record at a Tennessee hospital the use of the visit codes with the highest reimbursement rose 82 percent after the implementation of an electronic health record. The Times reported that "representatives for both hospitals said the increases reflected more accurate billing for services."
Electronic health records have been shown to drive costs up in other ways also, for example, by prompting physicians to order more tests.
And part of the motivation behind a move toward "bundled payments" and "accountable care organizations" and care coordination efforts is a recognition that fee-for-service billing games infuse the whole health system to a frenzy.
Now that most physicians in the United States are employees of hospitals or big healthcare corporations, we find a new source of scrutiny upon our charts. Quality improvement efforts, pay for performance schemes and all kinds other metrics center upon our notes in the record.
This can warp the purpose of the medical record. Instead of a document primarily meant to serve the patient, as well as something to serve present and future caregivers, the chart becomes a document primarily meant to justify financial remuneration for the institution. This wastes valuable time and resources. The worst examples are checkbox documents in which essential information is at risk of being overwhelmed by automatically generated data.
This introduces "mere scribbling" into our charts.
The experience of providing care then changes too, as we sit at screens, sometimes spending more time with the electronic representation of the patient than we have at the beside, mouse clicking our way through our exam and our orders, our documentation.
The caregivers would like to be remembered for what we do at the bedside, not in front of the screen.
While we take seriously how well our documentation helps our fellow physicians and nurses, we don't measure ourselves by how well our charts fit the needs of coding and billing -- but the people with power over us, healthcare businesspeople, administrators, insurers, do exactly that.
For now this seems an inescapable compromise we must make. As William Faulkner told his agent, “In some ways Proust was lucky. He didn’t ever have to contend with Hollywood for his bread and butter.”
Dr. Andrew Coates practices internal medicine in upstate New York. He is President of Physicians for a National Health Program.
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