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Beyond Coding and Documentation in Family Medicine

The specialty of Family Medicine recognized early in its development that effective, efficient information management in the ambulatory setting was essential to the success of healthcare delivery in the United States. Family physicians have envisioned and embraced the role of health IT to support the patient centered medical home and its focus on team, coordination, participation, and anticipation. Well before the incentives of Meaningful Use (though we are very grateful for the opportunity thus far), family physicians were implementing EHR systems in their ambulatory practices to improve the quality, safety, and efficiency of patient care. Our adoption of health IT has been a linear rise over the last 10 years. By the end of this year, over 80 percent of AAFP members will be using EHR systems in their ambulatory practices and our membership is now over 110,000 (and focused on primary care).

Historically, EHR systems have been document creation tools. But let’s face it, as physicians, that’s what we get paid to do. I tell my kids I am a professional writer. I don’t get paid to actually care for my patients. I get paid to write the official portions of their health stories (and apply administrative codes to them). We don’t get paid a fee for our service. We get paid a fee for our procedures. But not even really that. We get paid a fee for our documentation of our procedures. So it is not surprising that an industry developed to help us do just that. And, in fact, for many years, JUST that.

But we knew there was more, that the promise of health IT was beyond making sure we had all the bullet points to justify billing a 99214 (after years of under-coding because of the complex and ambiguous documentation guidelines and the threat of practice destroying fines). We began to see improved data access and clinical decision support tools at the point of care allow us to get more accomplished in a given office visit with higher levels of medical decision-making. We began to see improved quality measure compliance (and increases in associated procedures) because we were actually measuring and tracking things. But we also knew that collecting information important to a patient’s health, that creating and maintaining a patient’s coordinated health story was a collaborative effort that was only possible through advancing tools for communication, information management, and data sharing (all completely separate from creating a billable document).

Better data capture and availability means more coordinated, comprehensive, and appropriate care delivery. But data capture and coding must provide direct, tangible benefits to those doing the actual work. We didn’t become physicians just to be turned into coders and data trolls. What we do every day has to help people, to heal people.

Current codes are administrative, not clinical. Physicians have to wade through immense reference terminologies that are not designed for the way we think or conceptualize clinically. Coding of information is essential to its computability, reusability, aggregation, and analysis. But interface terminologies and established mappings are required to make these overwhelming reference terminologies approachable and to make clinical coding efficient and reproducible. It’s time to collect and code the information that matters to clinicians and their patients rather than actuaries and auditors. It’s time to pay for patient centered service, rather than hospital and clinic centered procedures (or, more specifically, their compliant documentation).

Successful health IT implementation and use in a family medicine practice requires reevaluating engrained paper-based workflows and finding new opportunities to improve access, efficiency, efficacy, and service. Successful health IT implementation and use in a first world healthcare system requires nothing less.

Jason M. Mitchell, MD
Director, AAFP Center for Health IT

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