Many of us remember searching frantically for a lost chart or misfiled laboratory result in the wee hours of the morning as we cared for a sick patient in the emergency ward, or requesting in vain the most recent note from a specialist about a patient who returned to our office after a consultation. The ultimate goal of the electronic medical record — a technological solution being championed by the Bush administration, the presidential candidates, and New York Mayor Michael Bloomberg, as well as Google, Microsoft, and many insurance companies — is to make all patient information immediately accessible and easily transferable and to allow its essential elements to be held by both physician and patient. The history, physical exam findings, medications, laboratory results, and all physicians' opinions will be collected in one place and available at a single keystroke. And there is no doubt that these records offer many benefits. We worry, however, that they are being touted as a panacea for nearly all the ills of modern medicine. Before blindly embracing electronic records, we should consider their current limitations and potential downsides.
As we have increasingly used electronic medical records in our hospital and received them from other institutions, we've noticed several serious problems with the way in which notes and letters are crafted. Many times, physicians have clearly cut and pasted large blocks of text, or even complete notes, from other physicians; we have seen portions of our own notes inserted verbatim into another doctor's note. This is, in essence, a form of clinical plagiarism with potentially deleterious consequences for the patient. Residents, rushing to complete numerous tasks for large numbers of patients, have sometimes pasted in the medical history and the history of the present illness from someone else's note even before the patient arrives at the clinic. Efficient? Yes. Useful? No. This capacity to manipulate the electronic record makes it far too easy for trainees to avoid taking their own histories and coming to their own conclusions about what might be wrong. Senior physicians also cut and paste from their own notes, filling each note with the identical medical history, family history, social history, and review of systems. Though it may be appropriate to repeat certain information, often the primary motivation for such blanket copying is to pass scrutiny for billing. Unfortunately, these kinds of repetitive notes dull the reader, hiding the important new data.
Writing in a personal and independent way forces us to think and formulate our ideas. Notes that are meant to be focused and selective have become voluminous and templated, distracting from the key cognitive work of providing care. Such charts may satisfy the demands of third-party payers, but they are the product of a word processor, not of physicians' thoughtful review and analysis. They may be “efficient” for the purpose of documentation but not for creative clinical thinking. Similarly, electronic medical records can reproduce all of a patient's laboratory results, often dropping them in automatically. There is no selectivity, because it takes human effort to wade through all the data and isolate the information that is pertinent to the patient's current problems. Although the intent may be to ensure thoroughness, in the new electronic sea of results, it becomes difficult to find those that are truly relevant.
A colleague at a major cancer center that recently switched to electronic medical records said that chart review during rounds has become nearly worthless. He bemoaned the vain search through meaningless repetition in multiple notes for the single line that represented a new development. “It's like `Where's Waldo?'” he said bitterly. Ironically, he has started to handwrite a list of new developments on index cards so that he can refer to them at the bedside.
True, handwriting in charts is sometimes illegible and can lead to miscommunication. It might seem that the printed (or at least typed) word, which we are all conditioned to respect, would always be more definitive and have more impact than text written by hand. But we have observed the electronic medical record become a powerful vehicle for perpetuating erroneous information, leading to diagnostic errors that gain momentum when passed on electronically.
An advertisement from a health care network touts the electronic medical record as the avatar of “High Performance Medicine.” The ad, whose headline reads “Medicine That Doesn't Forget,” shows a country doctor carrying a black bag. “Remember when physicians knew everything about their patients and carried all that they needed in a little black bag?” the ad asks. The electronic medical record, it asserts, “is the modern physician's equivalent of that little black bag. Only better.” But the attempt to link this form of technology with nostalgia for the family doctor who spent time in extended conversation and care seems rather incongruous. Indeed, this humanistic depiction of the electronic medical record contrasts sharply with the experience of many patients who, during their 15-minute clinic visit, watch their doctor stare at a computer screen, filling in a template. This is perhaps the most disturbing effect of the technology, to divert attention from the patient. One of our patients has taken to calling another of her physicians “Dr. Computer” because, she said, “He never looks at me at all — only at the screen.” Much key clinical information is lost when physicians fail to observe the patient in front of them.
The worst kind of electronic medical record requires filling in boxes with little room for free text. Although completing such templates may help physicians survive a report-card review, it directs them to ask restrictive questions rather than engaging in a narrative-based, open-ended dialogue. Such dialogue can be key to making the correct diagnosis and to understanding which treatment best fits a patient's beliefs and needs. One pediatrician told us that after electronically verifying use of seat belts, bicycle helmets, and other preventive measures, she has scant time to explore clinical issues. Electronic medical records may help to track outcomes and adherence to guidelines, but they may also force doctors to give “standard” rather than “customized” care.
These problems, we believe, will only worsen, for even as we are pressed to see more patients per hour and to work with greater “efficiency,” we must respond to demands for detailed documentation to justify our billing and protect ourselves from lawsuits. Though the electronic medical record serves these exigencies, it simultaneously risks compromising care by fostering a generic approach to diagnosis and treatment.
We are not Luddites, opposed to all technological interventions; we can see that electronic medical records have many benefits. Mountains of paper are replaced by the computer screen, with rapid access to complete and organized information, with risks such as dangerous drug interactions automatically flagged. But we need to learn how to use this powerful tool in the way that is best for patient care, regardless of whether it's the most “efficient” way.
We should instruct house staff that they must create independent, personal notes by talking to the patient and verifying the medical history themselves. We should discuss with payers what constitutes real documentation of time and effort rather than sleight of hand. We should use electronic formats that require us to select and insert specific, relevant laboratory results.
Perhaps most important, we should be cautious in using templates that constrain creative clinical thinking and promote automaticity. We must be attentive to the shift in focus demanded by electronic medical records, which can lead clinicians to suspend thinking, blindly accept diagnoses, and fail to talk to patients in a way that allows deep, independent probing. The computer should not become a barrier between physician and patient; as medicine incorporates new technology, its focus should remain on interaction between the sick and the healer. Practicing “thinking” medicine takes time, and electronic records will not change that. We need to make this technology work for us, rather than allowing ourselves to work for it.
Drs. Hartzband and Groopman report holding stock in Microsoft and Google.
Dr. Hartzband is an endocrinologist at Beth Israel Deaconess Medical Center and an assistant professor of medicine at Harvard Medical School, and Dr. Groopman is a hematologist–oncologist at Beth Israel Deaconess Medical Center and a professor of medicine at Harvard Medical School — both in Boston.
Not all timesavers are helpful
Simply implementing an electronic medical record (EMR) system won’t necessarily reduce your risk of an audit. On the contrary, if you don’t use the system’s documentation features properly, EMRs may actually increase your risk of an audit.
Bubble sheets—preprinted response sheets similar to those used in academic testing or research surveys—are used in some EMR systems for patients to report their family and medical history. According to documentation guidelines, anyone can provide or collect past family and social history, but the physician must sign off on the form before it’s entered into the record. Unfortunately, in many busy offices, the physician simply scans the bubble sheet before signing it.
“This might save time, but it’s essentially creating an invalid document,” said Mary LeGrand, RN, MA, CPC, CCS-P, a consultant with KarenZupko & Associates.
In one orthopaedic group, a bubble sheet listed possible symptoms such as fractures, joint pain, or spasms, but did not include an option for ‘no complaints.’ Additionally, the directions were unclear so that patients didn’t realize they were supposed to select all that applied.
Ms. LeGrand explained, “Because the bubble sheet had no negative response option, the EMR was automatically generating a note stating ‘negative for joint pain, muscle pain’—even though the patient hadn’t specifically responded to anything on the bubble sheet.”
In this case, the practice should have insisted the EMR vendor add a ‘yes/no’ option for all values under each system or provided a ‘no complaints’ option for each. (See sample PDF)
Collecting family history on bubble forms can also be an issue. “In a busy practice, proper collection of family history is sometimes overlooked,” Ms. LeGrand said. “That’s bad enough when the history is saved on paper, but in the electronic world, it’s even more dangerous. An EMR system that automatically populates information indicates there was some kind of response when, in fact, no information was ever obtained from the patient.”
Some vendors will claim that the EMR system will ‘code’ for you and help your practice make more money. Don’t count on it.
For example, one orthopaedic group noticed an increased number of high-level evaluation and management (E/M) codes after their EMR system went live. “They looked at the algorithm on the medical decision-making component and realized it was simply incorrect,” Ms. LeGrand said.
The system’s incorrect logic prompted it to suggest an incorrect, higher level E/M code. When the practice did an internal audit and recognized the inaccuracy, the billing team began to override the suggested code and bill the correct code.
At issue is the logic behind the code calculator itself. “Suggesting code levels that don’t match the documentation can put a practice at risk,” Ms. LeGrand warned.
Practices should be concerned about this issue, according to consultant Kim Pollock, RN, MBA, CPC. “Over the past 3 years, the percentage of 99214 and 99215 codes processed by Medicare has increased in almost all specialties.” According to an article in Part B News, the “proliferation” of EMR systems “allows easier documentation,” thereby justifying higher E/M levels. It’s likely Medicare may target these code levels for an audit sooner rather than later.
When shopping for an EMR system, ask the vendor to create a chart note using documentation from visits with patients who have conditions commonly seen in your practice. This will enable you to ensure that your “pick list” selections result in accurate documentation.
“I advise clients not to go live until all the customization is done and tested, and everyone understands how the EMR will affect patient flow and documentation workflow,” Ms. LeGrand said. “Physicians really need to access the system before it goes live and understand how it will change their workflow, and the flow of information in the practice. Otherwise, significant backlogs may occur.”
For example, backlogs can occur if the person creating the task list is not computer savvy or if the practice has insufficient staff to enter required health history information to open a visit note before a patient encounter.
Each practice will have to identify workflow changes and make the necessary adjustments. Because the vendor or information technology (IT) department rarely understands the nuances of orthopaedics, they won’t be able to help modify daily close processes or documentation/sign-off processes. Doctors, staff, and managers must pay attention to how the EMR will change the workflow and adjust processes.
In a “worst-case” scenario, the workflow in an EMR system could be so labor-intensive that documentation doesn’t get done at all.
The bottom line is this: Customizing an EMR and modifying processes and information workflow will take much longer than most practices expect. But, taking these important steps will reduce risk exposure and improve EMR success.
“Take the time to understand your documentation baseline, know your processes, and understand all the information flow points that are going to change,” advised Ms. LeGrand. “Otherwise, you’ll be sorry in the long run.”
Cheryl Toth is a consultant with KarenZupko & Associates, Inc). She can be reached at (312) 642-5616 begin_of_the_skype_highlighting (312) 642-5616 end_of_the_skype_highlighting or firstname.lastname@example.org
The Centers for Medicare & Medicaid Services (CMS) is also exerting increasing pressure on physicians to purchase HIT: financial incentives for using electronic prescribing through 2013 and rising penalties to practices that fail to employ this technology starting in 2012. The administration's stimulus package provides incentives for implementing and using certified EHR systems, while those practices that don't adopt these systems by 2014 will receive reductions in reimbursement.
Health policy advocates justifiably point to a myriad of potential benefits that should result from the widespread implementation of EHRs, from safe storage of health information to electronic sharing of clinical information. The knowledge shared through this access to patients' medical data promises to improve patient safety and reduce costs associated with duplicate and/or unnecessary tests and treatments. Electronic prescribing further promises to reduce medication errors, ranging from drug interactions to misinterpreted handwriting.
Most physicians who introduce EHR systems into their practices seek promised advantages for enhancing quality care and patient safety through the systems' touted data storage and retrieval characteristics. Electronic records offer immediate access to patients' documents and data.
Likewise, most physicians include among their highest priorities the goal of compliant evaluation and management (E/M) coding. Physicians believe they have a right to expect that these sophisticated and costly systems will ensure that they achieve compliant documentation and coding, thereby "making any E/M problems go away."
However, something has gone awry to create an environment that leaves well-intended physicians victimized when government audits reveal their software systems have allowed—even facilitated—submission of non-compliant and potentially fraudulent claims for E/M services. In the midst of increasing storm warnings of non-compliant designs, physicians are increasingly vulnerable to severe financial penalties.
This devastating storm has been developing for many years, often bolstered by an unintended lack of effective policies from several organizations that should have the best interests of physicians, patients, and the healthcare system at their core—organizations such as CMS, the Certification Commission for Healthcare Information Technology (CCHIT), and the U.S. Department of Health and Human Services (HHS), as well as EHR software vendors and physician training institutions (for more information).
Analyses of problems with EHR systems by physicians and their practice managers consistently reveal that the overwhelming preponderance of their challenges relate to the rarely discussed data-entry characteristics of the electronic history and physical (H&P), not to the heralded data-storage and retrieval features of their systems. One physician personally reported that "The software forces me to enter clinical information in a preloaded format; when I see a patient three weeks later, I cannot find any individualized details of the previous visit or understand why I did what I did."
In April 2008, a study published in the New England Journal of Medicine reported similar problems, pointing out that "Notes that are meant to be focused and selective have become voluminous and templated, distracting from the key cognitive work of providing care. Such charts may satisfy the demands of third-party payers, but they are the product of a word processor, not of physicians' thoughtful review and analysis. They may be 'efficient' for the purpose of documentation but not for creative clinical thinking."
The study also reported an example of the consequences of these problems: "A colleague at a major cancer center that recently switched to electronic medical records said that chart review during rounds has become nearly worthless. He bemoaned the vain search through meaningless repetition in multiple notes for the single line that represented a new development . . . Ironically, he has started to handwrite a list of new developments on index cards so that he can refer to them at the bedside."
Too often, these problems have proven insurmountable. At the Second HIT Summit in 2005, Mark McClellan, MD (then the administrator of CMS), reported "40 percent of attempted implementations fail." According to the April 1, 2006, issue of CIO Magazine, "The [Health and Human Services] department itself has acknowledged that the failure rate for EHR system implementation is 30 percent to 50 percent. Some healthcare network providers claim it is as high as 70 percent."
These electronic H&P challenges can manifest in one or more of four interrelated areas:
When audits reveal lack of compliant documentation generated by physicians using an electronic H&P, the findings can be viewed as the "canary in the coal mine" to warn of additional impending dangers related to data integrity, quality of care, and malpractice protection.
During the last several years, a significant number of articles have pointed out compliance problems intrinsic to the majority of current EHR systems. Chief among these relate to coding engines that fail to consider medical necessity, which CMS describes as "the overarching criterion for payment," and certain types of data-entry functionality that result in "cloned documentation," in which the records of every visit read almost word-for-word the same except for minor variations confined almost exclusively to the chief complaint.
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."
In 2007, HHS and the Office of the National Coordinator for Health Information Technology (ONCHIT) published an extensive report on "Recommended requirements for enhancing data quality in electronic health record systems." The section that reviews E/M documentation features (and analyzes current certification criteria for these EHR features) advises that "EHRs provide a variety of tools that enable a provider to be more efficient when documenting an encounter . . . These tools include the use of defaults, templates, copying, and others. The report then continues with the warning: "[These tools] can be extremely helpful if used correctly; however, the tools can also open the EHR [system] up to fraud or abuse."
The problem that physicians face is that most current EHR system designs have failed to incorporate protections to ensure the correct use of these shortcut tools. Without such "error proofing," it is not feasible for physicians, while concentrating on patient care, to differentiate the settings in which these various tools can be used compliantly from those circumstances in which their use could lead to pliant or even fraudulent documentation.
Let's summarize. Where are the storm fronts forming this perfect storm coming from? An EHR system "weather map" reveals the following:
Ms. Grider, Ms. Linker, and Ms. Thurston are three compliance experts who were called in to assist different physician groups during federal and state audits of those groups' electronic H&P records, conducted either by individual Medicare Carriers, Recovery Audit Contractors (RACs), or the Office of the Inspector General of the HHS. In each of the four cases, the audits revealed pliant E/M claims that were submitted as a consequence of physicians using their EHRs in accord with their particular designs for E/M documentation and coding.
The four practices employed between 1 and 10 physicians. The government audit evaluated between 20 and 100 charts per physician, and the percentage of charts failing audit for each physician ranged from 20 to 95 percent.
As a result of these findings, each practice was assessed a significant penalty for pliant documentation and coding. For the practice with the lowest percentage of failed audits, the final determination required repayment to Medicare of approximately $50,000 per physician. For the other three practices, the repayments ranged from $150,000 to $175,000 per physician. For at least one of the practices, the audit also imposed an administrative requirement of prepayment review for 100 percent of all future Medicare claims.
Even though each practice was using a different EHR, there was remarkable similarity in the design and functionality limitations identified as the causes of their compliance problems:
The authors who reviewed the records and audits for these practices observed that while many EHRs present one or more mechanisms to automate documentation of required history and examination elements, from both the compliance and the data-integrity perspective, automation is not documentation.
The added danger is that such automated documentation can also distort physicians' optimal care and workflow, and destroy data integrity. For example, in one of the reviewed practices, use of the EHR's preloaded macros for the physical examination actually created automatic documentation indicating that females had received prostate exams and males had negative pap smears.
The outcomes of these federal audits have been devastating, emotionally as well as financially, for the physicians and staffs of the practices involved. The failure of the EHR systems to provide for compliant E/M documentation and coding, as well as protections against overcoding and undercoding, led to statistically remarkable increases in the percentage of claims submitted with level 4 and level 5 codes. This increase drew the attention of government auditors, and the medical records created using these systems most often could neither support the levels of care submitted (primarily due to documentation shortcuts creating "cloned" records) nor the medical necessity for providing such high levels of care (due to failure to consider the nature of the presenting problem).
The overall conclusion derived from these reviews is that electronic record systems should provide sophisticated designs and functionality based on physicians' optimal patient-care workflow. They should be required not only to guide physicians in providing high-quality care and creating compliant documentation, but to protect against designs that have the potential to disrupt optimal care and/or generate non-individualized and non-compliant medical documents.
The causes of this perfect storm must be identified and eliminated. In response to these imminent dangers, practices that are currently using EHRs should obtain assistance from E/M compliance experts. They should insist that their vendors eliminate all non-compliant documentation and coding functionality related to their systems' electronic H&P, replacing such features with effective documentation tools that are usable, efficient, and compliant.
Similarly, when practices investigate the possibility of purchasing an EHR system, they should include experts in compliance and quality documentation on their evaluation team. As a condition for purchase, they should also require that these systems be usable for their physicians, efficient, contain only compliant documentation and coding tools, provide only for recording of individualized, meaningful, and reliable clinical information, and promote the quality-care process.
Figure 1 illustrates a sample blueprint for certifying that electronic H&P designs are "operable as well as interoperable." It presents standards that meet physicians' common criteria for effective medical records. These standards advocate for creative designs that not only promote quality care and meaningful documentation, but that protect against non-compliant documentation and distorted care. Physicians and practice managers would do well to require that EHR systems meet such criteria before purchase or implementation.
It is incumbent upon physicians' professional societies to seek the assistance of compliance experts and initiate policies that require corrective action for the underlying causes of these currently identified EHR system problems. This effort can include the following initiatives:
As the Obama administration provides incentives for the much-needed adoption of electronic health records, it must provide protections that guarantee not only the sharing of information, but also that the process of gathering this information and the quality of the information recorded are optimized. 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. Stakeholders must structure an environment in which physicians receive appropriate training with effective and compliant documentation tools, in which software systems provide only compliant designs and protect against improper documentation, and in which governmental agencies eliminate non-compliant practices in their own organizations and mandate compliant designs in the software systems they are advocating and promoting.
Stephen Levinson, MD, is the author of the books Practical E/M and Practical EHR. He has long focused on the interplay between compliance and quality patient care, medical ethics and integrity, and the health of the healthcare system.Deborah Grider is president of the American Academy of Professional Coders National Advisory Board. Robin Linker is executive director of operations and auditing for the Association of Healthcare Auditors and Educators, and CEO of Robin Linker & Associates Inc. Susan Thurston is executive director of education for the Association of Health Care Auditors and Educators, and CEO of Coders Connection Inc.
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If you are contemplating the purchase of an Electronic Health Record (EHR) system, it is important that you and/or your physicians take time to review each system’s medical record templates. Many systems have predetermined templates that allow minimal customization. Other systems offer greater customization options for a higher price. The important thing to keep in mind is that an EHR template is nothing more than a boilerplate, written by a third party or “expert” to input clinical data. The inflexibility of this template presents series of fundamental problems that will crop up during everyday use, specifically:
One of the biggest dangers presented by templates is that they may set the standard of care to wich the physician may be held. Acceptance of an EHR template may be viewed as your standard of care. Therefore, when choosing an EHR system, physicians should consider the following:
The bottom line is that you should select an EHR system that best fits the needs of your practice or medical group, and that closely mirrors your practices current templates.
The introduction of electronic medical records in hospitals and clinics — dubbed the “silver bullet” of health care reform — appears to have varying effects on different types of primary care physicians, a UC Davis study has found.
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Doctors are pushed to adopt electronic medical records harder than ever before.
However, costs are often the prohibitive obstacle, and whether the current generation of EMRs improve patient care remains in question.
But what about liability? Surely, more complete, legible medical records would reduce the risk of being sued. Right?
Well, it’s not that cut and dry.
In a story from American Medical News, doubts remain as to whether EMRs reduce the risk of being sued. The biggest problem is that most EMR charts are template-driven, meaning that superfluous, and sometimes inaccurate, information often creeps into a documented patient visit.
Several lawyers acknowledge further downsides, including, “the default settings of an EMR could present fewer opportunities for physicians to add information to medical records,” and, “EMRs also could provide too much information. For example, risk could increase if the EMR generates alerts or supplementary information and physicians don’t act upon them.”
(The reference to “adding information” is, I believe, a reference to the fact that EMRs discourage free-texting, as opposed to adding information after the fact.)
Current electronic medical records have a hard time talking to one another, which is essential to realizing their potential to reduce medical errors and improve patient outcomes. Until they do, the effect of EMRs on reducing medical malpractice is tepid at best.
Still not convinced Tempate-Free Charting from Praxis EMR is the best thing you could do to improve your practice?