Thursday, April 23, 2009

Pitfalls in EMR documentation

Recently I’ve posted a couple of anecdotal reports of documentation and coding fraud driven by electronic medical record documentation tools. I could just see the Medicare auditors licking their chops when I read those reports. Now those fears are confirmed. A recent Medical Economics article reports:

Recent audits by federal agencies confirm the warnings about E/M compliance dangers accompanying documentation shortcuts introduced by many current EHR software designs. These audits are a clarion call for stakeholders to eliminate the problems they have created, however unintended.

So how does an auditor know whether or not you actually did a twelve system review? From my read here are some ways EMRs get docs in trouble:

1) The EMR tools drive (sometimes almost force) documentation that is excessive for the severity of the presenting problem. The patient who comes in for a sprained ankle gets a twelve system review and family history because the EMR automatically imports such text, then the folks in your coding department bill accordingly. Medicare looks to see whether the severity of the patient’s problem matches the documentation, and if it doesn’t it’s a red flag.

2) The EMR tools generate implausible documentation, e.g. the one year old who is oriented times three, or whose pupils react to accommodation.

3) The templates generate multiple records with nearly identical text. This is a red flag which may cause the Medicare recovery auditor to cast a deeper and wider net.

4) The templates default to multisystem reviews and exams whether you do them or not, and it takes time and trouble to edit them out. If too many of your notes are so rich in documentation the auditor will look askance.

Not long ago a physician pitching a certain EMR product showed how to generate a complete H&P with a few mouse clicks. Very little editing was necessary, he told us, because almost all patients who presented with that particular problem had similar findings.

Unfortunately doctors are being held to a double standard regarding the old maxim: if you didn’t document it you didn’t do it. So don’t expect the Medicare auditor to believe that just because you did document it you did do it.

Although the article focused on coding and documentation, other downsides of the EMR were mentioned:

Physicians have long been counseled that a well-documented medical record provides the best defense in the event of a claim of medical liability. The June 2008 issue of the Journal of AHIMA quoted EHR legal expert Patricia Trites on the potential danger of electronic systems that permit copying of near-identical documentation into large numbers of patient records: "From a medical-legal standpoint, what would [lawyers] do when they [see] this chart?" she asks. "They are going to rip it apart."

One of the commenters noted:

I have personally been an expert witness in 5 malpractice case in two years caused directly by EHR's. The Veterans Agency EHR, touted by many as one of the top systems was involved in 2 of them. I counted 1012 pages of template heavy notes in one simple 8 month long chart and 157 times that this patient was supposedly screened for PTSD. Who are they kidding?

I frequently review records faxed from outside hospitals on patients admitted to my service. The ones which are electronically generated, including those from the VA, are generally so full of electronic clutter that I have a difficult time deciphering what really happened to the patient let alone what the docs were thinking. It’s electronic illegibility, often much worse than doctors’ handwriting.

H/T to Kevin MD.


Jay Andrews said...

EMRs can lead to loss of the human touch in health care. In the process of digitalization, the interpersonal aspect in health care may be lost. In handwritten hospital charts, doctors and other health care practitioners may write what they think and they feel based on their personal observations in their very own words. EMR is simply about ticking off boxes and crossing out things in electronic forms. The doctors are forced to think in categories and can seldom express a personal opinion on an individual case. Because of the lack of flexibility of many electronic reporting systems, cases of misclassification of patients and their conditions have been reported.

Samuraidoctor said...

Template driven EHR's contain multiple discrete points of potential error. Although they will list complete exams at a simple click, in order to tailor them to the patient (and no, most people do have their differences, no matter the commonality of the complaint), you must spend an inordinate amount of time hunting down each point of variation and documenting is.

We have had an EMR since 2004 at our clinic. There was an initial uptick in coding due to the exhaustive use of templates, but then documentation time consumed so much of the workday that we could increase productivity no further. The notes are either so little edited as to make it almost impossible to figure out what the doctor was thinking, or take approximately 5 times as long to document as the simple dictations of SOAP notes we were doing before.

This is all driven by coding. If we did it, but didn't write down every negative, we can't charge for it. Simple office notes now must have the format of an admission H&P, leaving me to long for the return of the SOAP note so that I could understand the notes of my colleagues, and make myself understood as well.

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