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

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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

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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

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*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:

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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