MSHUG Revisited: Documentation and Evaluation / Management coding solutions for future EMRs

Last week it was my pleasure to mingle with physician colleagues and developers at our bi-annual Microsoft Healthcare Users Group (MSHUG) conference on the Microsoft campus here in Redmond.  I also had the honor of delivering the closing keynote; a talk I'll be presenting many more times this year at our Healthcare Executive Forum events across America and at other select venues and conferences in the USA and elsewhere around the world.

While at MSHUG, I had a delightful conversation with Dr. Stephen R. Levinson.  Dr. Levinson, a retired Otolaryngologist and
AMA/HCFA E/M coding expert, recently published a book on a rather dry, but very important topic; "Practical E/M Documentation and Coding Solutions for Quality Patient Care".  Dr. Levinson was particularly engaged by a session at MSHUG on "A Common UI for the Electronic Medical Record:  Lessons from the NHS".  The session reviewed work Microsoft is doing to develop a more common user interface for clinical systems in the United Kingdom.  He also attended a session I hosted on the use of the Microsoft Office System in healthcare where there was some lively debate on the need for more intuitive, less costly solutions for clinical documentation.

Dr. Levinson shared thoughts with me on what he sees as a significant deficit in most EMR applications on the market today.  Rather than try to regurgitate his thinking in my own words, I asked Dr. Levinson to send me a high level synopsis outlining his point of view.  Although rather long for a Blog post, it is definitely worth a read if you are a developer of clinical systems or a clinician concerned about providing quality care for your patients and being paid appropriately and fairly for your clinical acumen.  Here's what Dr. Levinson had to say:


Although there are many elements of health information technology, each of which drawing primary attention from different stakeholders in the healthcare environment, physicians’ primary interests and requirements in transitioning to an electronic health record revolve around the electronic version of the physician’s history and physical (H&P). As background, we must appreciate that the physicians’ H&P stored in the paper format (using writing and/or dictation for data entry) has also created significant problems for physicians for many years. Although student physicians learn the quality benefits of performing and documenting a comprehensive history and physical examination, the fact that medical schools have failed to provide students and residents with medical record tools to accomplish these tasks in the time frame required during residency training and medical practice has led physicians to adopt problem focused shortcut charts (such as “SOAP Notes”), which promote non-compliant E/M documentation and coding.

Just as we know that our medical records should reflect the care we provide, physicians must be aware that the care we provide also reflects the content and functionality of the medical record we employ. Although physicians have commonly viewed documentation and coding compliance as an unsolvable problem, the recently published “Practical E/M” approach introduces the concept that incorporating compliance and efficiency into medical record methodology and design can be applied as a solution to the challenge of E/M documentation and coding. It is highly recommended that physicians incorporate this approach into their current paper records as an initial step towards understanding the medical record features they require, prior to identifying the essential structure and functionality they need in EHR’s in order to fulfill their H&P requirements.

Current physician challenges to success with the current generation of electronic health records can be localized to the data entry elements of the medical H&P. Physicians should require structural design and functionality that both permit and guide the entry of individualized, patient-specific information that is required to meet medical standards of quality care, compliance, efficiency, usability, and productivity. However, current systems commonly incorporate documentation shortcuts, originally introduced to meet time constraints, which restrict the scope of documentation through the use of limited-vocabulary pick lists and pre-set templates, resulting in loss of individualized descriptions. The resulting similarity of records among multiple visits and among multiple patients has impaired both quality and compliance. Recently, the Centers for Medicare and Medicaid Services (CMS) have even instructed carriers to audit E/M claims based on electronic medical records because of automated documentation, upcoding, and lack of consideration of “medical necessity.”

Applying Practical E/M medical record criteria (compliance, efficiency, medical record usability, quality documentation, and productivity levels appropriate for severity of patient illness) to EHR data entry structure and functionality promises to overcome current issues and promote HIT success. In overview, this effort calls for an in-depth evaluation to ensure that the H&P structure is designed to guide physicians in performing and documenting all of the required E/M elements, including medical necessity and each of the nine sub-components of medical decision making. It also requires re-evaluation of two cornerstones of EHR functionality: 1) the physician should assume the role of “data entry operator” (i.e., should personally enter all data into the electronic record), and 2) all entry of data should be synchronous with the time of the patient encounter. The consequences of these two primary assumptions ripple through all aspects of usability, compliance, efficiency, and quality of data entered in the current generation of EHRs. In various software systems, these consequences may include loss of ability for new patients to complete screening medical history questionnaires without physician time, loss of necessary physician entry of individualized narrative (i.e., free text) descriptions of history of present illness, abnormalities in the review of systems and other components of medical history, detailed analysis of abnormal examination findings, and descriptive valuations of elements of medical decision making. In some systems, this has also resulted in automatically uploading medical data documented in prior visits, a process that is non-compliant and can also compromise quality care.

Since a compliant and efficient E/M solution is currently available, now is an optimal time to turn a critical eye on the development of the next generation of the H&P component of EHRs, bringing compliant design and introducing maximal flexibility to allow all options for data entry. This should include providing for the possibility of using asynchronous entry of written and transcribed information by data entry professionals (rather than physicians). When added to all the options for synchronous entry by physicians (including typed information, handwriting recognition, and voice-recognition), this functionality will promote the entry of high quality individualized narrative data and eliminate limited and non-compliant pre-structured templates and pick lists.

Since E/M compliance is the established requirement for documentation and coding of the medical history and physical, applying this standard to the electronic health record provides a sound basis for establishing a much-desired “common user interface.” This can promote interconnectivity and communication between physicians who have different EHRs, and the same approach can reasonably be applied to the evolution of personal health records to ensure similar interconnectivity and communication.

It has been said that opportunity comes cleverly disguised as an unsolvable problem. E/M compliance presents such an opportunity for creating an effective solution to the current challenges caused by the physicians’ H&P component of electronic health records.


If you would like additional information on this topic, please visit Dr. Levinson's web site at  In the meantime, I look forward to seeing you somewhere down the road at a future Microsoft Healthcare event. 

Bill Crounse, MD       Healthcare Industry Director        Microsoft Healthcare and Life Sciences 


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