E/M Coding Alert - 2012 Issue 5
EMR Implementation: The Good, the Bad, and the Ugly of EMRs: Keep This Advice Handy And Make A Potentially Bad Situation Better
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Article Overview
This piece reviews practical and compliance-related considerations for emergency department teams and coders using electronic medical records. It covers the transition from paper or templated charts to EMR systems, the impact on productivity, the role of scribes, documentation integrity concerns such as cloning and macros, privacy and business associate considerations, and the broader regulatory environment driving EMR adoption. It is most relevant for coders, billing staff, compliance personnel, and clinicians working in ED documentation and EMR implementation.
Why This Topic Matters
EMR workflows can change how documentation is created, reviewed, and coded, which affects compliance risk, audit exposure, and productivity. Understanding the article helps readers recognize common documentation pitfalls and the administrative pressures tied to EMR adoption.
Article Sections
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Background and EMR adoption
Introduces the move toward electronic medical records and the broader policy context behind adoption. Summarizes the expected operational and documentation-related changes associated with EMR use.
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Drawbacks and transition challenges
Discusses common frustrations encountered when moving from older documentation formats to EMR-based workflows. Focuses on finding information, chart length, and productivity impacts.
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Scribes: help or hindrance?
Addresses the growing use of scribes in emergency department settings and the compliance considerations that can accompany them. Also touches on workflow and productivity effects during system ramp-up.
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Beware clones and macros
Reviews audit concerns related to repetitive or copied documentation and the use of macros in electronic records. Also notes federal review activity and the importance of individualized documentation.
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Bridge the HPI to HIPAA gap
Covers electronic access to prior records and how that can support coding and billing review processes. Also highlights privacy, security, and business associate agreement considerations.
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Watch the regulatory rules for your future
Summarizes the incentive and penalty environment tied to EMR implementation and meaningful use requirements. Explains why future coding workflows are likely to be affected by these rules.
What You Will Learn
- How EMR adoption can affect emergency department documentation and workflow
- Why productivity and chart review challenges may arise during EMR transition
- What compliance concerns are associated with scribes, cloned documentation, and macros
- How privacy and business associate considerations relate to electronic record access
- Why federal incentives and penalties influence EMR implementation timing
Who Should Read This
- Medical coders
- Billing and reimbursement staff
- Compliance professionals
- Emergency department clinicians
- Health information management teams
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