Eyeworld

DECEMBER 2023 | EYEWORLD | 41 C Relevant disclosures Bartlett: None Christensen: None Zhu: None Contact Bartlett: bartlett@jsei.ucla.edu Christensen: stephen.christensen@hsc.utah.edu Zhu: dagny.zhu@gmail.com the numbers in the chart with my laser surgical technician just before hitting the pedal," she said. While these safeguards and surgical tim- eouts are not built into the EHR, Dr. Bartlett said EHRs do have some safety measures. For example, if a patient has listed an allergy and a doctor tries to order a medication they're allergic to, the system would flag it. It also flags dosages that might be considered unsafe. From a business standpoint, medical docu- mentation errors can be costly, not only in terms of OR resources, if a patient needs to be brought in for an additional procedure, but also in terms of insurance denials and the staff time needed to correct these issues and resubmit. Mr. Christensen gave an example. He said the Moran Eye Center recently underwent a "Target, Probe, and Educate" audit for cataract surgery. The findings included documentation omissions: "Per LCD L37027, documentation must include an attestation supported by docu- mented symptoms and physical findings in the medical record indicating that the patient's im- pairment of visual function is believed not to be correctable with a tolerable change in glasses or contact lenses. This attestation is not present in the documentation. Also per LCD, documenta- tion must include a statement that a reasonable expectation exists that lens surgery will signifi- cantly improve both the visual and functional status of the patient. This is not supported in documentation submitted." Mr. Christensen said in response to these findings, the physicians were given a stan- dardized documentation protocol for cataract surgery to follow that would coincide with their exam findings. He also said that in partnership with University Medical Billing, a percentage of their office visits are reviewed for accuracy. Based on the prospective review, "changes are made to bill the appropriate level of service for the work that has been documented," he said. "Our coding team collaborates effectively with our surgeons to ensure cases are coded ap- propriately. In the event that a mistake is found, communication is sent to the provider for clarifi- cation and correction. Recently, a laterality error was identified in a section of an op note. The mistake was identified, the provider emailed, and an addendum created to correct the mistake prior to the release of the claim." Mr. Christensen said that their EHR is reg- ularly updated, which helps facilitate accurate and timely documentation. In general, "careful attention to the accu- racy of documentation is critical to the safety/ treatment of the patient and success of the business," Mr. Christensen said. Pro for paper Dr. Zhu said she likes having everything in one place and being able to spend more time "face time" with the patient rather than on a computer. "I can review a chart and see the OCT, to- pography, biometry simultaneously. It's also easy for me to handwrite notes in the chart to do calculations or highlight important findings when making my final IOL selection. It's a little cumbersome when everything is electronic and you have to open different windows to do those same evaluations," she said. Pro for digital While EHRs are, to some degree, "univer- sally hated" among ophthalmologists, Dr. Bartlett said, enhanced communications facilitated by the electronic record is a plus. "There have been times in the past when I've gotten paper records and I can't make out anything on it, so it's zero information," he said. "I think there is a value in being able to better communicate among physicians, to communicate with patients, and that leads to better patient care."

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