EHRs and audits mean new roles for physicians, staff

This essay is part of Medical Economics' 2013 Physician Writing Contest. Click here to enter the 2014 writing contest.

With the introduction of electronic health records (EHRs), and the increasing use of audit results and quality measures for payment, it is clear that the traditional nurse and front-office staff job descriptions have to be revamped. As doctors have to meet more and more requirements to get paid, they need to rely heavily on their staff to collect and enter data that insurers will review and use to determine payments. 

The traditional nurse position is no longer just rooming patients, taking blood pressures and triaging health concerns from patients over the phone. And the standard front-office worker isn’t just pulling charts and scheduling appointments.

In our group practice of 30 providers in seven offices, we had to reassign tasks to staff that hadn’t changed their daily routine in many years and didn’t want to have their job descriptions rewritten.

It is human nature to resist change, so the easy acceptance of EHRs in general was not always easy for either doctors or staff. However, it was necessary to make the change, and so we did. Of course there was a lot of grumbling and some difficult days. But the harder part now is figuring out how we shift our staff from their pre-EHR roles to the new ones required in the post-EHR era.

Added responsibilities for nurses

Let’s start with the nurses. They are now required to do much more than just rooming a patient and taking and entering vital signs. In order to reach meaningful use goals, they must enter whether or not the patient smokes. They have to reconcile the current medications and click the appropriate box. They have to review the allergies and click the box.

In the fall, they need to ask a patient if he or she has had a flu shot, and enter the answer in the computer with the proper current procedural terminology (CPT) code for the doctor. This is far more time-consuming than the old way, and the nurses feel stressed about it. They can no longer make patient phone calls between bringing patients back for the doctor, because they don’t have enough time. Nurses on the phone are also struggling. Every encounter now is more time-consuming, because the EHR system is inherently slower than paper charts.

It is not as easy for the nurses to multitask, because they can only have one chart open at a time. At the end of the day, they don’t feel as accomplished as they normally would because the ‘jelly-beans’ (phone messages) are no longer always empty.

For data entry, we originally tasked the nurses with trying to enter the patient’s mammogram, colonoscopy, and Tetanus, Diphtheria, and Pertussis vaccination information from the paper chart into the computer while rooming the patient. This just bogged the nurses down, and was simply too time-consuming. Digging through paper charts to find the exact date of a colonoscopy performed 7 years previously was not cost-efficient, nor did it allow for a reasonable workflow that kept the doctor on time. We decided, therefore, to have our front-office staff enter some of this data.

Next: Asking more of Front-office staff

Asking more of Front-office staff

Traditionally, the front-office staff abhors anything clinical. They don’t even like delivering a stool specimen in a brown bag from the patient to the nurse. The very idea of holding a full cup of warm urine was vile to them. Also, having to be responsible for adding data other than just demographics to a chart was foreign to them. The front-office staff wasn’t comfortable notating mammograms and hemoglobin A1c levels. However, because they were less busy with the billing, thanks to the computer system, they were the obvious choice to enter data the insurance companies crave.

With a little encouragement, the front-office staff took over the majority of the audits. Now they diligently look up the data in the paper charts, and enter it into the EHR. If no mammogram results are in the paper chart, they check the EHR. They know to look under “alerts,” and if it hasn’t populated there, to check in the “diagnostic imaging” results, and if not there, then in “patient documents.”

If they don’t find a record of the required test, the front-office staff now sends the patient a letter from the doctors explaining the importance of the test for the patient’s health. Included in the envelope is a requisition for the test, and a letter to sign and return if the patient refuses to get the test. Some insurance companies now accept a refusal as a completed test. The front-office staff will scan the refusal letter into the EHR, so the doctor gets credit for asking.

A high school student also helps to enter data. He was hired initially to help the front-office staff enter problem lists and medications when we were first implementing the EHR system. After a year, when most patients’ basic information had been entered in the EHR, his job evolved to entering immunization records for patients under age 18. Recently his responsibilities changed yet again to entering results of mammograms, colonoscopies, and dual X-ray absorptiometry scans performed pre-EHR. We did this because it is now crucial for the practice to have all of the audit data in place so that we aren’t penalized at year’s end and lose money.

Questions change with new data requirements

As staff members become more comfortable with the EHR, everyone is getting a little faster. The nurses are now required to ask patients aged 65 and over about falls and enter the answers under preventative measures before they bring the patients back for the doctor. As the audits and quality measures change year to year, the questions the nurses ask will change as well. In the future they may assess alcohol intake and urinary incontinence issues before the provider even enters the room.

The doctors’ role has changed too. When reports come in and need review, the doctor tries to populate the alerts to make information easier to find during audits. Physicians also need to enter the International Classification of Diseases-9th Revision and CPT codes, and check off the evaluation and management code before the patient returns to the front desk to check out.

 This may sound no different than when we used paper bills, but it is. It requires finding the proper code, and opening and closing many boxes to get all the information entered properly. However, it makes the biller’s job easier, leaving him or her more time for audit work.

Doctors are also performing more data entry than ever before while still trying to make eye contact with patients. Doctors are entering their own referrals during the office visit rather than requesting their nurse to do so. This frees up some time for the nurse to do her other new tasks. So the shifting of responsibilities is an unremitting challenge with the EHR system, and will continue to transform our practice well into the future.

Our office continues to strive to provide the highest quality of care possible to our patients. It is sometimes difficult to do so while trying to enter so much data for the insurance companies. Unfortunately, without the data, reimbursements go down. Without adequate payments, there will be no practice to provide care for our patients.

Fortunately, our staff understands this dynamic and is quite cooperative with the process of transforming traditional job roles and responsibilities into new ones. As medicine evolves in the new EHR era, it will be crucial for office staffs to accept the changes. Job descriptions will need to be rewritten, and hopefully this will contribute to improved patient care.