Dynamic Chiropractic – June 20, 2006, Vol. 24, Issue 13

Science Fiction or Digital Documentation

Will the Red Pill Reveal That Paper Has a Limited Future in Your Office?

By Steven Kraus, DC, DIBCN, CCSP, FASA, FICC

"We have nothing to fear but fear itself."
- Franklin D. Roosevelt, March 4, 1933

"I think you know what the problem is just as well as I do ...
This mission is too important for me to allow you to jeopardize it."

- HAL 9000, in "2001: A Space Odyssey"

Dystopia. It's kind of an eerie word, isn't it? If you are near my age or older, you've probably seen your share of dystopias in your lifetime, mostly on the big screen. Think of Mel Gibson in "Mad Max," Governor Schwarzenegger in "Total Recall," or Keanu Reeves in "The Matrix" trilogy. I know at least "The Matrix" is on your cultural radar. If you want to take it back a generation, we could talk about the iconic Charlton Heston as the astronaut befriending the endearing talking monkeys, such as Cornelius and Dr. Zaius, in "The Planet of the Apes." Every one of these cult favorites had characters living in a futuristic age in which things were not as they seemed, and the entire world was a bit off kilter; a dystopia. It's the kind of place some of us feel we inhabit with the increasing demands of clinical documentation, especially in this age of HIPAA. It's almost as if Big Brother is watching.

Actually, Big Brother is watching. Recently, his name was the Office of the Inspector General (OIG) of the Department of Health and Human Services. For many of us, OIG still is the name for Big Brother, although tomorrow, Big Brother may very well be someone different, perhaps someone in our very own state licensing and regulatory boards. According to "the report" from the OIG, which I mentioned in my last article,1 chiropractic had a 94 percent error rate in documentation during the time of the Inspector General's study. It's a number that has led our own regulatory bodies to encourage taking action against DCs with poor levels of documentation. By "action," we're not just talking about refunds and audits, but about suspended licenses or probation for substandard documentation. No matter who ends up looking over our shoulders, the powers that be in Washington, D.C., and our own state legislators will be noting what takes place in our profession, for the simple reason that they're keenly interested in the future of all health care, especially as it relates to the development of electronic health records and the possibility of reducing bloated health care costs.

It's true that the Health Insurance Portability and Accountability Act of 1996 aimed to improve patient rights and privacy in this electronic age, but it also was a strong federal endorsement of all health care offices moving to a paperless model. As the Centers for Medicare and Medicaid Services has written in their overview of HIPAA: "Adopting these standards [HIPAA] will improve the efficiency and effectiveness of the nation's health care system by encouraging the widespread use of electronic data interchange in health care."2 With the last of the HIPAA deadlines approaching in 2008 and most of the law now in effect, the federal agenda has a legal backbone and a set of standards against which it can enforce a federal mandate for digital documentation. I believe, as President Bush has suggested on a number of occasions, that such a mandate may go into effect as early as 2015. This reality and the revelation of our own substandard practices means that travel cards and "chicken scratch" are out; they won't be found in the practice of the future. Instead, details with transcription-style clarity or printed notes are in.

The good news is that many of us appear to be ready to embrace this future of improved electronic documentation. I only say "appear" and "many" because there's still some legwork a lot of us need to do in order to either (1) convince ourselves that digital documentation is a necessity; or (2) educate ourselves about what a truly digital model of office management looks like, and the benefits and consequences it might have for our documentation practices and our pay scale.

As of 2005, it was estimated that 98 percent of chiropractors have at least one desktop computer that they use for office management, typically for billing. As I've talked to chiropractors across the country about their management systems, I know that "at least one computer" is not generous enough. Many of you run some kind of software scheduler and perhaps manage a clinic Web site, in addition to the billing and insurance programs that you currently use.

Even with this technical experience under our belts, many chiropractors are hesitant to admit that total digital documentation is a coming necessity, for reasons we might only call an inherited technophobia. In spite of the entrepreneurial character that typifies a lot of our colleagues, I believe this reticence over technology is a critical part of our chiropractic DNA. Looking to the past, we know that entire chiropractic colleges were divided, and new colleges were founded, over the issue of clinical technology; for example, the use of the X-ray as a tool for examining the anatomy of the spine and seeking possible pathology. A number of teaching faculty left the Palmer School and started their own programs when the Palmers started using the X-ray in the early part of the 20th century. The Thompson drop table is another example. While there wasn't the same controversy as with X-ray, its novelty, like any technology, was not met with complete acceptance immediately, which is now hard to imagine given the ubiquity of drop tables in our practices. Chiropractic is just simply not as technology-driven as the medical world is, and rightfully so. Certainly some of us are gearheads, and we've got a few gadgets and gizmos around our offices that were supposed to be the "next best thing." For the most part, however, we're pretty conservative when it comes to investing in future technologies.

So, to the technophobes among us, I say this: When it comes to digital documentation and electronic health records, fear not HAL 9000. For those of you not old enough (or odd enough) to know, this classic character from American cinema continues to live anytime anyone of us begins to feel we're losing control to the machines that were meant to convenience our lives. Ever feel you can't escape your cell phone? That you can't do anything without the Internet at hand? That's the HAL effect: the fear that we're being betrayed by the very technology that was meant to help us. HAL 9000 was the supercomputer in the film "2001: A Space Odyssey" that murdered the astronauts whose lives "he" was programmed to protect simply because they threatened "his" mission. While many may not be familiar with HAL, many of us are familiar with the feelings engendered by a technology that we don't fully understand when it is suddenly foisted upon us.

Instead of fearing an unknown technology, why not talk to your colleagues who have invested in a truly paperless system, and see if they've experienced what you currently fear? Is it really more convenient? Is it really HIPAA-compliant? Does it encourage payment from third-party payers because documentation is more complete and more capable? Or has it revealed holes in their documentation practices they never thought they'd find? It might be an enlightening discussion. If you don't know anyone who has gone paperless, that still shouldn't stop you from investigating what your own practice might look like if you made such an investment.

In his inaugural address to the United States during the depths of the Great Depression, Franklin Delano Roosevelt made history by exclaiming, "We have nothing to fear but fear itself." Now, in a far less iconic way (but just as sincere), I say, "We have nothing to fear but poor documentation." While it's definitely not as eloquent as FDR, it's an appropriate turn of phrase for our profession.

In my last column,2 I expressed that worry over the OIG's report was simply unnecessary, provided that we see current developments as an opportunity rather than a hindrance. Today, I repeat that sentiment. Instead of being afraid, let's act proactively to avoid a true chiropractic dystopia. Let's embrace the tools that will help us succeed in documentation. But let's do it cautiously and with ample forethought. The smart application of technology that fits with our current and future office needs can be a freeway out of the desert. Rather than passively wonder what the future holds for us, let's act and make the future ours.


  1. U.S. Department of Health and Human Services: The U.S. Center for Medicare and Medicaid Services. Regulations and Guidance, HIPAA General Information. www.cms.hhs.gov/HIPAAGenInfo.
  2. Kraus S. The silver lining in the OIG report. Dynamic Chiropractic, May 8, 2006. www.chiroweb.com/archives/24/10/19.html.

Click here for previous articles by Steven Kraus, DC, DIBCN, CCSP, FASA, FICC.


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