Tuesday, August 27, 2013

Problems with EHR templates and other documentation tools

EHRs were touted early on as time savers while facilitating documentation in support of better reimbursement. The real world truth, as has since been discovered, is that it doesn't work that way if you want to be in compliance. And the regulatory compliance people are getting wise to that fact according to a recent article in Today's Hospitalist. If you want to be in compliance, say the authors, you either need to dictate, free text or spend a significant amount of time deleting and editing. Sorry, that's just the way it is.

From the article:

Hospitalists would never order an MRI scan unless it was medically necessary. Ditto for laboratory studies. But that can all change at the bedside where physicians may not think as much about medical necessity and instead go with their standard scripts for review of systems and physical exam.
Asking a patient with a femoral neck fracture about polydipsia? Probably a stretch. Cranial nerve examination on a patient with a diverticular abscess? Abuse, for sure, and potentially fraud.
That last one doesn't compute for most hospitalists. MRI scans cost thousands of dollars, but cranial nerve examination is just words on paper. What's the big deal?

My favorite is “pupils equal and reactive to light and accommodation.” I don't know about you but I have not checked accommodation in years.

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