Can we automate E&M coding in EMR systems?

Another thought provoking article by my friend John - here. E&M Coding guidelines are so old. They're from 1995 and 1997. If we look at what the guidelines say, it starts with the basics - whether the patient encounter was Brief (1-3 elements)or Extended (4 or more elements). This is just for the History of Present illness, where HPI Elements include: location, quality, severity, during, timing, context, modifying factors and associated signs/symptoms.

This is the easy part.

Then you look into 'complexity', data reviewed, and 'risk of complications'.

We are not at a point where 'systems' can evaluate risk and complexity. Also, as doctors frequently tell me, it may not be a complex case or may not be that high of a risk, but if the patient is talkative, and I spend more than 30 minutes with the patient, my level of coding may jump up.

Secondly and more important, these guidelines may be rendered totally obsolete if healthcare reform progresses where reimbursements would be tied to 'continuum of care' rather than pure 'episodic'.

Just additional food for thought.

Continuous EMR Training

This is a must Read Blog - Click here. John is always very inspirational. But this time, he touched on something that just happened yesterday.

A very good client (a Wonderful Physician in Florida) of mine called me couple of days ago. They had been a good EMR user for a couple of years, but thought they can do better. Thought they needed to ‘graduate’. So, we spent half an hour online, and ‘discovered’ he can save at least 45 minutes per day just by tweaking things.

Spot on John – - Continuous Training - Continuous Improvement

I've seen too many EMR users try to cut corners, cut costs by avoiding one of the most important elements of a successful EMR software implementation.

It is my humble appeal to all EMR users - Web based EMR, or Client Server EMR; Please don't compromise not only on ample initial training, but also ongoing training.