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Thread: EMR ruins coding & documentation

  1. #1

    Cool EMR ruins coding & documentation

    AAPC: Back to School
    I've been coding E/M services for three years now. Got used to different docs documenting their own way. We just went to an EMR and it is not good. Yes, you get the bullets and the HPI elements because of the TEMPLATE built in to the software, but they are meaningless as far as documentation goes. How do you tell someone in administration that what is being documented is useless? They picked out the software, so they want to hear how great it is. Yes, we are being forced to do this: thanks Medicare. If you use they system the way it's intended to be used, it creates really bizzare sounding paragraphs and are difficult to read on a follow up visit. So does this make documentation and treating a patient more accurate? No. It makes it worse. Once again, thanks Medicare.

  2. #2
    Join Date
    Apr 2007
    Dover Seacoast New Hampshire


    First, I sympathize.....About five years ago, my coding staff and I were force-fed a practice management system/EMR that we had no input in selecting. In fact, the rumor at the time was that this magnificent piece of technology would soon put the coders out on the street.

    At the time, I decided that if I wanted to retain my job (and thanks to children and a mortgage, I absolutely did), I would have to jump on this EMR bandwagon. So, I made it my business to assist our facility in making sure that our software was easy-to-use as well as compliant.

    Although I sympathize with you, I'm going to go out on a limb here and tell you to put your big girl (or boy) pants on and show your providers what you are made of. You're right...an EMR gives you canned, impersonal documentation. But you can make this a golden opportunity for yourself. Start with implementing an small internal audit of a handful of medical records. Point out areas of opportunity (improvement), and areas that could be compliance concerns--and back up your suggestions with regulatory guidance. You don't want to provide just your opinion, because of course it will look like you're simply upset about the change in status quo. Then make sure you present a reasonable solution to the concerns you've brought up. Offer to help with education, template development, or workflow improvement. Learn that EMR program inside and out, and how to work behind the scenes to make customizations that will improve the software. Become a team player, and avoid ranting and complaining, because EMRs are here to stay, and if you want to remain employed, you're going to have to learn to love it.

    Medicare is not forcing us to do anything.....remember, providers do not have to contract with Medicare....so it's a choice that your practice has made. Did they consult you, or think about coding/compliance/documentation when they chose software? Apparently not, but don't let that bother you. Make this an opportunity to use your coding knowledge to help them tweak this software. No EMR is useless....it simply needs some adjustments and customization, and you can be the hero here, if you simply re-think your approach.

    Did our EMR put the coders out on the street? nope....we've tripled our coding staff, and most of them work as auditors/educators, with a much bigger salary than your average staff coder. The EMR was the best thing that ever happened to us.
    Pam Brooks, MHA, CPC, PCS, COC
    Coding Manager
    Wentworth-Douglass Hospital
    Dover, NH 03820

    If you can dream it, you can do it. Walt Disney

  3. #3
    Join Date
    Apr 2007


    I agree with Pam in saying we can't blame medicare for the bad templates/documentation. I would do exactly as Pam said and audit the notes and point out the inefficiencies during the result meetings.

    Good luck..
    Dawnelle Beall, CPC, CPMA, CPC-I
    Licensed AAPC PMCC Instructor
    AAPC ICD-10CM Certified Trainer

  4. #4

    Unhappy How amny of you are on the street because of EMR /EHR

    " In fact, the rumor at the time was that this magnificent piece of technology would soon put the coders out on the street. "
    100% true , "the EMR system know how no knowledge" kept me on the street, before I could get there on to coding the arena, where I am confident about and place my whole strength on. No employee is ready to take you without EMR/ OR 'know how' to swiftly change on to New EHR system. It seems Latin for some us. Can not shell out money again to pull out the knowledge of EHR system. Some make such a great oullah-bullah about it so much so that the coding certificate is null and void. What is this great hierchial status about EMR than the coding talents / skills the coders have?
    In other words, the IT technology opted to totally rule over the medical technology and place us on to the dust bin.
    Is there any option on this present day, of going into coding without the EHR system thrushed in. If so let me know.
    No organization is willing to train the coders (mainly the new coders) on this path. They wish to have a "digital ready reckoner IT MEDICAL CODER" !!.
    I would not be surprised if it comes to pass yet another section of IT in the CPC certification to get through along with the 150 questions. !

  5. #5
    Join Date
    Apr 2007
    Dover Seacoast New Hampshire


    You don't have to be an IT specialist to carve out a niche for coding in the EMR world. But you do have to understand the documentation guidelines and be able to instruct your IT team that this is what is expected for compliance, and you have to understand how software works, so that you can make suggestions for improvement. We've all seen a lot of technological changes in the past few years, and unless you want to go the way of the dinosaurs, you'll definitely have to adjust. I remember (yikes) a rotary phone hanging on the wall in my mother's kitchen. Now a blackberry not only sends me phone calls, but I can text, surf the net, and schedule my life all within a hand-held device. You have to stay current....in coding as well as in technology.

    I see a lot of worrying going on in this board....about not being able to find work, about losing work, and even not being happy with current work. First...if you're unhappy about your situation, none of the rest of us can change that for you. We can make suggestions, but ultimately, your life is in your own hands. If you're unwilling or unable to adjust to this ever-changing industry, then perhaps this isn't going to be the career for you. There, I said it.

    Those of us who have found success (and passion) in this field can only direct the rest of you to what has worked for us, or towards what we see as the upcoming trends. It's entirely your choice as to whether or not you're willing to move towards the future of the industry. Entering the coding field these days with no computer literacy is career suicide. Even physicians have to be software-savvy, so nobody is exempt from today's technology. I work for a facility in which the coders are second only to the IT people as the 'techno geeks'. Not a bad place to be, actually, and in fact, my facility spends a great deal of time, energy and money making sure we are all educated and trained, so it's not true that employers are unwilling to invest in their employees. Frankly, if you aren't proficient in Word, Excel, Powerpoint, e-mail, scanning technology and don't understand how software applications work, you're going to find yourself unemployable in about five years, so you might just have to suck it up and invest in further education, unless you plan to win the lottery.

    Those of us who can see the forest through the trees are trying to offer some advice for those of you who ask, but I'm not going to sugar-coat the message...I simply want to fairly present what I see as the future of the industry.
    Pam Brooks, MHA, CPC, PCS, COC
    Coding Manager
    Wentworth-Douglass Hospital
    Dover, NH 03820

    If you can dream it, you can do it. Walt Disney

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