CCCC 2015 Presentation

1. The Risk And Value of Economizing Language
in the Electronic Patient Narrative
Susan Rauch CCCC 2015 Presentation
Texas Tech University Technical Communication & Rhetoric

2. RISKS AND REWARDS:
EHR CONSTRUCTED ILLNESS NARRATIVES
 How the EHR artifact itself employs economic
thinking through rhetorical patterns of
organization.
 How EHR narratives represent rhetorical and
economic units of value in an attention
economy.
1) Transaction Hazards
2) Revenue Leakage
3) Narrative Landscapes

3. In an attention economy where digital texts
compete for users’ attention, how does EHR
technology affect the social, communicative,
and economic practices of health professionals
in the workplace?
 How do EHR generated narratives represent rhetorical units
of measurable value and exchange in an attention economy?
 What are the risks and benefits of economic organization and
cost efficiency of the electronic patient health record?
 What is the net gain of economizing the patient narrative in
electronic health technology?
RESEARCH QUESTIONS

4. Richard Lanham (2007) – Applied Theory: Economics
of Attention
Joyce L. Carter (2005) – Applied Model/Theory:
Applied 3D Model of Real-World Rhetoric (Economic
Texts)
D. Sittig and H. Singh (2010) - Applied Model/Theory:
Sociotechnical Systems(STS) Theory / 8D Model for
Studying HIT (
Oliver E. Williamson (1991) – Applied Theory:
Transaction Hazards and Economic Organization
RHETORIC AND ECONOMICS: THEORETICAL
FRAMEWORKS AND MODELS

5. 3D MODEL OF REAL-WORLD RHETORIC +
8D MODEL OF APPLIED PRINCIPLES OF STS THEORY
3D MODEL (Carter)
How market mechanisms influence
participants to “make decisions about their
resources” (Carter 6)
8D MODEL (Sittig and Singh)
Addresses socio-technical challenges of health
information technology in the workplace
Aligns with 3 EHR Narrative Landscapes:
 Technological, Informational, Economic

6. 3D MODEL OF REAL-WORLD RHETORIC: Identifying
EHR as Rhetorical Product with Economic Value
PRODUCTIVE
Social
Circumstance
CRITICAL
Text in Society
INSTRUMENTAL
Text and
Presentation
Informational &
Economic
Informational
Technological
EHR LANDSCAPES

7. PRODUCTIVE
Social
Circumstance
CRITICAL
Text in Society
INSTRUMENTAL
Text Production
and Presentation
• Begins with critical and analytical
• Engages in more activity
• Moves further away from text
• e.g. Management, Value, Organizational
Theory, Project Management
Production and Style at starting
point e.g. Ethics, Cultural Criticism,
Gender, Technology Criticism,
Humanism
Dimension that remains closest
to the text itself e.g. Grammar,
Layout, Style, Editing, Logic
TEXT

8. KAIROTIC SHIFTS: Clinical Documentation
Handwritten Typed
RISK: ILLEGIBLE INFORMATION REWARD: CLEAN INFORMATION

9. KAIROTIC SHIFTS: Clinical Documentation
Electronic
FEATURES
•Non-Sequential
•Non-linear
•80/20 Rule
•Hypertextual
Prose
Risks and Rewards: Also See Session Handout

10. RISKS IN CLINICAL DOCUMENTATION:
ILLEGIBLE HANDWRITING
RISKS
• Revenue Leakage (loss)
• Net Gain =0 (denial of
claim)
• Misinterpretation
• Liability

11. Complexity of Coding Systems:
Key Differences in ICD-9-CM v. ICD-10-CM
Source: hscrc.maryland.gov

12. CODING THE EHR NARRATIVE: Risks in
Economizing EHR Narrative
RISK: Errors of Omission/Commission
(Missing or Incorrectly Assigned Codes)
Code Sets as metaphoric expressions of a patient’s diagnosis narrative
Source: aapc.com
Conversion mapping of code sets

13. 3D MODEL OF REAL-WORLD RHETORIC + 8D Model
of Applied Principles of STS Theory
PRODUCTIVE
CRITICAL
INSTRUMENTAL
8D: Clinical Content;
People; Internal
Organizational
Features
8D: Hardware and Software;
Human Computer Interface
8D: Workflow and
Communication;
Measurement and
Monitoring; External
Rules and Regulations
Informational & Economic Landscape
Informational Landscape
Technological Landscape
Risks in Economizing the EHR Narrative

14. CASE STUDY: Revenue Integrity and the
Risk and Rewards with EMR/EHR Setup
RISKS/REWARDS: UMC Revenue Integrity –
Revenue Leakage (loss)
Found $209,000 in net review on 1 incorrect charge
code/CPT setup
UMC Business Intelligence Report Projection
Move to electronic charge sheets =increased gross
revenue 125%
Source:
Micky Allen, MBA, Director Revenue Integrity
UMC Health System- HFMA

15. CODING THE EHR NARRATIVE: Risks and Rewards
in Economizing EHR Narrative
Transaction Hazards
 Mismatched Charge
Codes with CPT Codes
 Errors of
Omission/Commission
(Missing or Incorrectly
Assigned Codes)

16. Coding the Diagnosis/Illness Narrative:
Risk & Rewards with ICD-9 to ICD-10 Coding
Differences Between ICD-9 and ICD-10 Code SetsRISKS
• Re-Training and Education
• Difference b/w 50k+ codes
• Unspecified codes =
unspecified illness
narrative
• Revenue leakage
• Structure: Minimal
Medicare claim
line/character allowance
REWARDS
• Specified codes
• Improved revenue
• Illness narrative clarified
• Improved Structure and
increased line /character
allowance

17. Workplace Solutions:
Reduction in Transaction Hazards
PROBLEMS
Clinical systems: Not matching billing processes
Ex: UMC outpatient PT assigning codes to handwritten
narrative – facility assignment error
EHR Systems: No universal standardization
SOLUTIONS: Compliance and Accountability
Education and Training of Staff
 Reduce errors in documentation, revenue capture,
and interpretation (assignment of coding)
 EHR technology and simulation training methods
Source: Micky Allen, MBA, Director Revenue
Integrity UMC Health System- HFMA presentation
April 2013

18. FORTHCOMING RESEARCH
National Survey: HFMA Membership Revenue Integrity
and Cycle Management Experts
Site Observations: Hospital simulation testing and
training events using test patient records
Interviews (complete): HIM, HIT, PT, RI
Design/Document Analysis: EHR template/landscapes
Rhetorical Analysis: Published Revenue Integrity
presentations and white papers related to EHR clinical
documentation and transaction hazards.

19. REFERENCES
Allen, Micky. “Creating a Revenue Integrity Culture for Revenue Maximization
while Ensuring Compliance.” HFMA Lonestar 2013 Major League Institute.
Arlington, TX. 20-12 May 2013.
Carter, Locke. "Rhetoric, markets, and value creation: An introduction and
argument for a productive rhetoric." Market matters: Applied rhetoric studies
and free market competition. Ed. Locke Carter. Cresskill: Hampton Pr, 2005, 1-
52. Print.
Lanham, Richard A. The Economics of Attention: Style and substance in the age of
information. University of Chicago Press, 2006. Print.
Sittig, Dean F., and Hardeep Singh. “A New Socio-Technical Model for Studying
Health Information Technology in Complex Adaptive Healthcare Systems.”
Quality & Safety in Healthcare 19.Suppl 3 (2010): i68–i74. PMC. Web. 12 Mar.
2015.
Williamson, Oliver E. "Strategizing, economizing, and economic organization."
Strategic Management Journal 12.S2 (1991): 75-94.Wiley. Web. 10 Dec. 2013.