In addition, vendors are helping. “EMR vendors are getting smarter about the tools and are designing the notes more meaningfully for people, giving individuals and organizations the ability to make a better note,” Jacobs says optimistically. He is excited that some vendors have added the ability to use highlight tools in the note. This is important, he says. Without highlighting, the text has all one look and feel, though some of the information could be drastically more important to know. “The difference between ‘coding’ and having a rash is a big difference,” he says.

“You would think a lot of this would have been obvious from the beginning,” Jacobs says. He attributes some of the lack of these capabilities to the failure of EHR vendors to get end-user input in the design process.

End-of-day note

EHRs pose a big problem with “copy forward.” Clinicians were copying and pasting the same end-of-note from the day prior, for days on end, yet “no two days are the same for a patient,” Jacobs says. These notes should never be the same. It negates the whole idea of an end-of-day summary. The cut and paste capability is the culprit for this in EHRs. Paper notes always had a fresh end-of-day note “scribbled” by the physician.

Jacobs was able to work with his EHR vendor to block the cut and paste capability enterprise-wide in some cases, particularly with the end-of-day note. Problem solved. Jacobs made it clear end-of-day notes should be a fresh summary.

Problem lists

Even before EHRs, physicians have always been challenged to keep an up-to-date problem list, which is now a core requirement under Stage 1 of the EHR incentive program.

“Until meaningful use, there wasn’t a lot of incentive in most organizations to keep one,” Jacobs says. “The Joint Commission would come by and say, ‘where is your problem list?’ And people would scramble.”

In addition, problem lists often have a smattering of descriptions for the same problem. They aren’t consistent. Jacobs wanted to fix that.

In the end, the best solution was to have the EHR programed to prompt the clinician who writes a problem in the note to add it to the problem list. This can be automated, prompting the clinician to select the problem from a drop-down menu to include in the list as s/he describes it in the note. “It encourages them to keep a problem list,” he says.

Billing

Last, but not least, Jacobs wanted to find a way to make billing quicker, more efficient and less painful. Back in the days of paper, the doctors would drop off their notes every three days or so in a box in the billing department and just pray things would all work out. “We left a lot of money on the table.”

Interface the note with the bill. Put a little section in the note that allows the physician to select the CPT codes for the day’s work. “The way we sold this to the doctors was to tell them, ‘you have to write a note every day anyway.’” If they could also select the CPT code, that will only facilitate quicker reimbursement. We begin billing that night.

In conclusion: the five-part obligation for the physicians in Jacob’s ‘one note per day per patient’ plan is:

• Write the note
• Select a diagnosis
• Select the CPT code
• Make sure the note has the right date
• Sign it

Of course there was some brief mandatory training, but the go-live to EHRs went well, including the ‘one note” plan. “It was sort of an easy sell,” Jacobs said. “For the most part, people pretty widely embraced it. It was much more successful than I thought it would be.”

This article first appeared in Government Health IT, a sister publication of Healthcare IT News.