Chisels and screwdrivers

You surely know the difference between a chisel and a screwdriver, but have you thought about what happens if you ignore the difference?

It is problematic – but possible – to drive a screw with a chisel.  (I know. I have trashed chisel to prove it.) But there are consequences, mostly not good. The chisel doesn’t become a screwdriver just because you are misusing it. The job is much harder than it would be with the proper tool. The risk of injury is higher. And the chisel will never do its real job properly again.

The same is true with medical records. Originally a clinical tool used by clinicians to record and share medical information about a patient, the health record has been, to great degree, co-opted as a billing tool.  In order to function as a billing tool, it has been necessary to modify it with artificial internal structures related to billing requirements but unrelated to the care of the patient. Its use as a billing tool requires attention by the clinician to billing requirements: how many bullets in how many systems, is that information recorded where the coder in the business office can find it, have I recorded enough negative answers to (often clinically irrelevant) questions to justify a well compensated billing code?  Much of what goes into today’s hybrid clinical and billing note is important for payment but irrelevant for care. Recording this takes time, distracts from relevant information, and can disguise and distort the clinical narrative. In order to support a broken piecework and volume based payment system it has become progressively less useful as a clinical tool.

One way to address this would be to expect the clinician to use the medical record as a clinical tool, and then have coding and billing staff evaluate the documentation and code the visit for billing. This would allow clinicians to focus on care and patient and clinical needs and would make the records a far more useful and usable tool for care. If you suggest this to your medical organization, guess who will be loudest opponent? The business office.  Why? Because when clinicians focus on care rather than billing while caring for the patient and documenting the visit, the information that is recorded in the note is tailored to care (which improves) rather than revenue generation (which declines).

Since billing became tightly tied to wRVUs and dependent not on what was done but on what is recorded, the tail has been busy wagging the dog. As Mr. Natural says: "Get the right tool for the job!"


Mr Natural


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