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Information Exchange... Where's the Beef?

August 1, 2008
by James Feldbaum
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First, let me acknowledge my strong support for Heath Information Exchange. What concerns me, however, is the present state of CAC (computer assisted crap) that is generated by physician coding-optimization programs that are imbedded in EMRs. By imbedding superfluous exam elements and long-winded verbiage that’s only raison d’être is to upcode (aka optimize reimbursement) we have diluted the value of our clinical communication. It reminds me of the old punch-line “with all of this horse sh-t there has to be a pony somewhere.” Now, I am not casting stones. I too performed and documented exam elements of dubious value to be certain that my records documented services commensurate with my billing codes. While not cheating (the questions were asked and the exam performed) I unintentionally diluted the true value of the pertinent information gleaned from the visit.
CIOs, programmers, legislators, and vendors have little concern for the value of the information that is exchanged. It is all about “exchange”, not “content”. I blame the payors. They have made “documentation” the Holy Grail, not information. A physician note or consultation has become a quagmire of computer generated/assisted text that doesn’t merit exchange.

Let’s build a Healthcare system that honors and promotes the exchange of real information. Now we have “garbage in… garbage out… garbage passed along”.

I'm not dumb. I just have a command of thoroughly useless information.
Bill Watterson (1958 - ), "Calvin", It's a Magical World



Much appreciated feedback. I too have hope. You are right, the nurse's note used to contain great narratives that contained useful clinical information, both explicit and subtle. It was the first page I turned to when charts were still on paper.

jim, isn't this eactly why any sort of medical record based off claims activity is useless to physicians. They know better than anyone that, sometimes, coding isn't about the actual treatments being given.

All valid observations.

1. The economic (payor) perspective has brought us codes (e.g ICD-9) that clinically are a farce at best an objective distortion. For example, in some cases hyper-XXX and hypo-XXX have the same billing code. Doctors tell me this is insulting. The existence of the word, nosology, is a bad sign and telling.

2. The regulatory perspective has, in some cases unnecessarily, caused clinical documentation to be unreadable and useless to doctors, when that wasn't the case, say, 10 years ago. I hear every week from practicing physicians in hospitals, "I hate nurses notes they aren't what they used to be and should be." Nurse executives often agree.

3. Regarding "garbage passed along" - There is objective signs for hope on that one. The CDA4CDT as well as the CCR initiatives have been directly focused on addressing the challenges you clearly elaborated. I'm guessing that you and half the readers of this blog clearly understand that. For those who dont, adding tools, policies, standards, and validation processes, documents can become both efficiently informational, and, under-the-covers, containing information for other-than-clinical purposes. And, concurrently bring semantic interoperability ... another term for the Holy Grail you referenced.

To bring this full circle with your intent and other blog posts on this site, the "objective signs for hope" are going to require Leadership. Leadership on the part of those managing these processes, to sanely make 'documents' what they need to be.

As a former technology exec who decided to become an RN, I appreciate Jim's comment on the usefulness of nursing documentation hee hee...

On a serious note though, the ability to capture and exchange appropriate clinical information is paramount. It's all about the patient, the care, and the provider's ability to deliver.