title: Lightening the burden of the heavy regulatory hand an incentive for outpatient computer patient record.
abstract: However many benefits may be achieved for the organization, it is difficult to introduce a computer patient record (CPR) into an outpatient setting until the clinical practitioners themselves see direct benefit from the time invested. The ever increasing burden of regulation on health care in the outpatient setting includes (but is not limited to) guidelines for evaluation and management (E&M) coding, Local Medical Review Policy (LMRP) rules for diagnostic justification of tests and procedures and associated requirements for Advance Beneficiary Notification (ABN), and the rules for teaching physicians in academic settings. Achieving compliance with just the LMRP rules requires immediate access to an eight-inch-thick stack of manuals (ICD9, CPT, HCPCS, and LMRP), 4 inches of which is subject to update on a monthly basis. Accurate E&M coding is about as complicated as using the long form to do one s tax return. Without tools that can be provided by the CPR, these requirements add significant time to the patient encounter and significant risk of non-compliance and fines. We report our strategy for deploying the CPR as a strategy to keep clinicians from being overwhelmed by the rules, thereby allowing them to focus on healthcare. In the context of the CPR, and against all odds otherwise, the impact of the regulations can sometimes have beneficial and educational impacts on clinical care.
authors.affiliation: Division of Clinical Informatics, Information Systems Department, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
authors.forename: K
authors.initials: K
authors.lastname: Walker
authors.forename: J R
authors.initials: JR
authors.lastname: Flanagan
authors.forename: T
authors.initials: T
authors.lastname: Lane
mesh_terms: D001291:Attitude of Health Personnel; D003625:Data Collection; D003933:Diagnosis; D004194:Disease / Q000145:classification*; D006801:Humans; D016347:Medical Records Systems, Computerized; D009936:Organizational Innovation; D010044:Outpatient Clinics, Hospital / Q000331:legislation & jurisprudence / Q000458:organization & administration; D014584:User-Computer Interface