A known problem with electronic medical records is the use of template-based documentation.
This saves a tremendous amount of time, as paragraphs upon paragraphs of information can be documented with a single keystroke.
Problems arise when doctors, inadvertently or not, document history or physical exam findings that do not exist. The issue occurs more often than you think, and with the traditional mindset of “if you didn’t document it, it didn’t happen,” does the opposite extreme hold water?
Or, as #1 Dinosaur writes, “It seems that more and more doctors are taking that to mean that if something IS documented, then whether or not it actually happened is moot, at least as far as payment is concerned.”
Should doctors, who know of others who fraudulently document, blow the whistle, or issue a more subtle warning to the offending physician?
Related posts:
- How electronic medical records can lead to coding fraud, and get doctors into major trouble
- Documentation
- The New York Times finally gets it on electronic medical records
- Can Wal-Mart help doctors implement electronic medical records?
- How the widespread adoption of electronic medical records can raise health care costs
- How to fund electronic medical records wisely
- Poll: Will electronic medical records really save money?
{ 23 comments }
So many of these programs can populate a huge field with a single mouse click–loading the last full exam or a completely normal exam, wherein details of one or two aspects of the exam can be changed to suit, even if the time and attention hasn’t been given to justify all of the other “normal” findings.
EMRs suit the coding requirements nicely, pumping up the volume of “noise” that nonetheless qualifies as history and exam documentation, while obscuring the essentials that better handwritten documentation did well. We have diminished the utility of good notes with these easy features.
Any more, I look only at the impression and plan on a printout text of an EMR note; the other stuff is usually just only so much wasted space. Worse, gone are the easy-to-identify data trees with pertinent lab and other numerical values. Combing through the text for these nuggets is no time savings at all.
this is yet another reason why the way in which health care, and primary care in particular, is reimbursed must change. Providers will use templates because it helps ensures that they will get paid for what they have done. When this incentive is removed (along with some malpractice reform), reading EMR’’s will become more appreciated and thus more widely adopted.
This is an issue with paper charts as well; people document a set series of negative physical findings. Even if maybe they didn’t listen for bowel sounds, they are so used to the pattern of writing, that the odd thing will slip through eg:
GI: N BS, non tender, no masses, no organomegaly, no stigmata CLD . . .
I’ve seen this in primary care and consultant offices alike, whether
I agree with Dr. Mintz. I see this happen every day, on almost every chart. However, I don’t think it is really a big deal in terms of a patient’s medical care. Which is the point. A 15 min patient visit will require another 10 min (at least) for charting. From the patient’s perspective that’s barely 50% of the doctors time actually in the room with him or her. As a patient, I could care less about how “thorough” my doc is with his charting compared to face time. But the lawyers and billers care only about the document. There’s a real conflict of interest here. The physician has to decide and patient is on the short end of the stick.
1. Fraudulent documentation is not a function of EMRs. It is a function of unscrupulous providers of care.
2. EMRs produce typeset electronic documentation which by its nature is more readable than the handwritten notes from the majority of healthcare providers. I do understand that many EMRs suffer from the lack of proper formatting of the data, but there are some EMRs that do produce very well formatted documents that all providers of care would expect to see from a formal dictation/transcription.
Bottom line. EMRs are here to stay, and they will make a tremendously good impact on healthcare. We are just at the painful beginnings of its true development. Please refer to Dr. Halamka’s recent post on setting expectations.
JFS
When you pay based on documentation, you get documentation based on pay. The medical chart is nothing more than a giant invoice.
What did we expect?
Don’t blame the EMR.
I grow weary of seeing residents writing “PERRLA” on daily progress notes. Many of them don’t know the A stands for accommodation, let alone how to test for it. I then tell them that when they write that without doing the evaluation, they render themselves untrustworthy. They don’t do it again, at least on my patients.
The courts don’t care about our physical exam findings, they only care about the radiological findings. So why should we care if the exam is actually done or not? I wouldn’t do anything if I knew a colleague was falsely documenting exam findings.
Happy’s post is succinct and unfortunately completely true. Is there really a reason to hit all of the bullets to get to a level three visit for a cold or an ankle sprain other than payment. There certainly is no medical reason for the exam and increased documentation.
The trump card is the complexity of medical decision making. Ignore the exam because you still have to make the level here, where the standard is the least well defined and the most subjective.
Re: comment by Dr. Sucher:
IMHO and experience, electronic medical records are GIGO – garbage in, garbage out.
I am TIRED of seeing my consults cut and pasted, when the writers have clearly NOT really seen the patient that day. I always document a meticulous description of the patient’s grooming, eye contact, energy level on every encounter [and when necessary, pt's dress]. I think this assessment is absolutely relevant to showing that you have looked at the whole patient in evaluating his/her health, function and ability to comprehend tx plan. It is also good defensive medicine to explain why you’ve chosen 1 plan over another, considering the complexity of plan, etc.
Others’ subsequent notes always include the SAME description, along with my dx/tx plan section which is cut and pasted.
Come on, are you going to say pts look the same every single day? It is just SO easy to crib information from a cut and pastable note, less so w/a manuscript note.
It is really easier to be unscrupulous when it involves very little effort.
Where is the wisdom we lost in information? Where is the information we lost in data?
In response to nyc.
1. “IMHO and experience, electronic medical records are GIGO – garbage in, garbage out.”
Again. The EMR is a tool. Tools can be used improperly. We don’t get rid of the telephone because of telemarketers. We aren’t dumping credit cards because of the economic crisis. We aren’t dumping the Internet because of identity theft. To suggest that the EMR is the problem is patently false.
2. “I always document a meticulous description of the patient’s grooming, eye contact, energy level on every encounter [and when necessary, pt's dress]. I think this assessment is absolutely relevant to showing that you have looked at the whole patient in evaluating his/her health, function and ability to comprehend tx plan.”
Personally, I agree that there is an enormous amount of information to be gained by the “foot of the bed exam”. However, It’s time : benefit ratio in documentation is minimal. Documentation is meant to tell a story. That story should be clear and concise and most importantly match the Assessment and Plan. The Assessment and Plan should be direct and obvious without ambiguity. This is the purpose of documentation. I understand completely concerning the ins and outs of billing and “defensive medicine”. I have made a choice to document exactly what I have done, and why I am thinking what I am thinking. I do not spend the time or energy to make a billing statement or worry about legal issues. I do this all by simply following the rules. I remain very fortunate and I do all of this in a very highly complex environment.
3. “It is really easier to be unscrupulous when it involves very little effort.”
This is an extremely poor argument against EMR. It completely ignores the benefits that are occurring and will occur as we improve these tools. Can you envision having a REAL medical record. One that actually starts with the patient’s birth. Is complete, and concise. That it contains all the information about the true medical history and medication list. This is where EMR/EHR is going. Can you not remember having to go to the radiology file room and wait for 10 minutes while the tech doesn’t find the film that you need to see? Can you not remember when you had to go to the micro lab to plate and stain your own slides? Can you not remember when exploratory surgery was the only way to make some diagnoses? We do not stop the advancement of tools because they have problems. We identify the problems and address them and move forward. This is the beginning. It is a tough road and it has been filled with so many potholes. But it will be a superhighway.
4. “Where is the wisdom we lost in information? Where is the information we lost in data?”
Exactly. This is a key point that I drive home in my presentations on information technology. There IS a key difference between DATA and INFORMATION. Data is just that… Data. It must be filtered, and put together with wisdom to give us the information that we need to support our decisions. Make no mistake. You and I are not smart enough to keep up with the mountains of data being generated, and the deluge of information that needs to be learned. We will need to harness the power of computing to do this job better. But it is up to you to take control from the administrators and politicians on how this technology is used.
JFS
The first comment was on totally on target. I review charts and one provider has produced completely identical physical exams on every single patient for 5 years.
One approach is just blow it off as irrelevant and look at impression and plans only, but, as pointed out by JB, once you show a pattern of documentation that is not a reasonably reliable indication of the truth, you have blown your trust, creating a lot of secondary problems.
Sucher is right that they are with us to stay, but “good impact” that exceed the destructive effects is yet to be proven. Unless he has a time machine, then his implication that this is an early stage to a better future is an act of faith alone. It may well be the beginnings of a nightmare.
I do a lot of chart reviews and there is no substitute for a dictated or legible written narrative using standard English with actual verbs and complete sentences generated by the mind of the examining physician for communicating a clinical picture of the patient that can be useful to future doctors in determining the actual course of illness.
It isn’t hard. Basic Junior High English exposition class combined with basic medical vocabulary will do nicely: “Show; don’t tell”. “Describe; don’t generalize.” Punctuation and spelling are optional.
The various cryptological shorthands for written notes, used judiciously, are fine too. There is nothing like script with the varying positioning, circling, stars, arrows, etc to convey to a colleague emphasis, alarm, or puzzlement.
While it is true that the chart is an invoice, it is “nothing more” than an invoice. Besides, if your falsify your invoices, why would I want to trust you with my life?
Hey anonymous 7:49 pm:
Why do you spend so much time reviewing charts?
Don’t you have a practice to attend to?
Or do you just like doing the dirty work for the insurance companies?
As far as I am concerned, you are like a prisoner who gets special privileges, in your case money, for policing your fellow prisoners.
A family practitioner
Well said anon 7:49. I suspect Dr. Sucher grew up with EMR, As one who is older and “grew up” (professionally speaking) before EMR, I find these notes mostly worthless. Our ER notes three lines of important info with 5 pages of crap. It’s a joy to pick outr the important data. When it comes to learning about a patient, nothing is like a non-template dictated note from another doc…period.
Anon 10:10. Let me clear the record. I don’t review charts. I am a practicing surgeon and surgical intensivist. I am posting all my opinions with my full name, and anyone can check on my credentials.
1. I did not “grow up” with the EMR. I have ran for my own xrays. I have plated my own slides.
2. I have however created an EMR. I created it based on the belief that it is the best way to advance medicine and help our patients. This will become true as long as physicians guide its development. I originally began programming computers in 1979. Back then I had no idea how powerful computers were to become. I lacked vision. I won’t make the mistake ever again.
3. It is perfectly understandable to harbor ill feelings towards past and many current generation EMRs. However, the idea that somehow a paper record is better than an EMR is shortsighted. I will for the last time make this clear argument that the EMR is simply a tool. That tool, like any other, can be used improperly or properly. It is the professional that controls its use.
Quite possibly I have not made my argument appropriately. Many EMRs of past and current generations have failed to deliver benefits for many reasons (suboptimal user interface design, poor integration with workflow, complexity of medical care, etc.). This is well documented in the literature and through simple historical perspective.
What I am arguing is that holding on to the paper record is like holding on to using a candle to illuminate a room when you have available the first light bulb. Sure, the light is dim and it burns out quickly. But if you can’t see the immense potential that it holds to radically improve healthcare and society, then you might as well continue to work in the dark.
JFS
Dr Sucher:
Maybe I did not make myself clear. I have no problem with an electronic medical record. I have a big problem with templates. In reality what is stated in a template may or may not have happened. Templates are not made for docs rather for billing. They clutter notes with worthless and frankly at times incorrect information. They make notes anywhere from hard to near impossible to read. Is it relly that hard to dictate your own note (and have it placed in an EMR)? I think not. Eventually I think the lawyers will probably “fix” the problem.
Yes. The templates are the first generation of the healthcare human-computer interface. It is poor. It creates extra burden on us as practitioners. It’s suboptimal implementation can and will be overcome. EMR systems can (and have been) created that effectively provide well formated, human readable transcriptions from well templated interfaces. It unfortunately is the exception and not the rule.
All that being said. Dictations and hand written notes leave a huge thing to be desired. That is… structured data. This is the problem that we face when trying to advance the science of medicine. We have so much information that is being lost because it is trapped in hand-written notes, and dictations (which, by the way suffer from mal-transcription. ie. what you dictate is missing or incorrectly transcribed.) Without investing in putting structure to our documentation, we decrease our ability to reap the reward that can help us advance medicine.
Finally to address one key point that you have brought up. To quote you.
“Is it relly (sic) that hard to dictate your own note (and have it placed in an EMR)?”
This is the opposite of EMR. This process is simply a transcription documentation system. It defeats what EMR is about. EMR is meant to house information in such a way as to provide decision support for healthcare. However, this is yet to be achieved on a wide scale. Places like Intermountain Healthcare and Regenstreif Institute would be the best examples.
Read this most recent article from the British Medical Journal.
BMJ 2009;338:b81 “Use of primary care electronic medical record database
in drug efficacy research on cardiovascular outcomes:
comparison of database and randomised controlled trial
findings”
Thank you,
JFS
I posted on this over a year ago. http://ermurse.blogspot.com/2007/10/templated-charting-sslippery-slope-to.html Yes you can do the same fraudulent documentation on paper by checking a series of boxes for a review of systems or using dictation templates but with most EMR’s a single click of normal populates a full set of findings across all body systems. Its called an exploding note. The root cause is the financial incentive to document a review of symptoms and lack of standards on design of EMR charting. The exploding note is the selling point of a lot of EMR vendors. There is also a feature called copy forward where you can copy an entire not forward to the current date and time and edit any changes. Problem is its usually only the date of exam that gets changed. Vendors promise you will be able to increase your revenue and decrease the amount of time charting. It plays well with susceptible providers who think no one looks at the note anyway. There needs to be some very public examples made of practioners who produce fradulant documentation to shake up the industry.
The CERNER EMR is the worst in the world. Frankly a hand written daily progress note use to be 1/2 a page to 1 page now you have a 5 page document. Also you have to hit “control enter” to go to the next line when you are typing in the what box. Unbelievable. Plus they make you “click” too much. In short I hate it.
Also, residents notes these days are essentially a copy of the prior days note and it is difficult to determine what changed in the patient from day to day because the same crap is denoted time and time again and is mostly useless.
In short, as a fellow on a consultative service…it is quite difficult reading the EMR to determine what happened during the course of a hospitalization.
Also, I find that I spend more time in front of a computer then I do spending time with patients…and if I am in clinic I look more at the computer screen then I do the patient. How absurb is that???? Medicine has become impersonable.
When I am an attending, it will be written in my contract that I may dictate ALL my notes and I will never type another note into an EMR unless I openly choose too….which I never will. Or they can provide me a mid-level provider to write all my notes (of course they will learn to write them MY WAY) that I will co-sign. That way I can do what I love, takeing care of patients instead of stareing at a computer screen all day. Of course, the only nice thing about EMRs is that labs are easier to look at.
Also, any hospital that employs the CERNER EMR…well lets just say that I will not be applying to that hospital for privildges. And that hopsital wasted a lot of money implemting that system…and if they want anything changes, Cerner will always say “Can’t be done.”
“you are like a prisoner who gets special privileges, in your case money, for policing your fellow prisoners.”
I am the prisoner referred to and actually agree with your implications 100%. It is shameful, but true. Shameful for all of us.
When the medical profession began taking the King’s shilling and capitulated to the world of socialized medicine, they became unfree. I say capitulated because the generation of docs first presented with it rejected it’s proposal but lost the argument. Then they accepted the money rather than stand and fight in the only meaningful way–non-participation. Current generations no longer even remember the love of independence and autonomy that made their fathers reject it. Rather most of our professional organizations clamor for more medical socialism, not less.
The fact of the matter is that some of the prisoners NEED policing. With the loss of freedom and autonomy that come with socialism come a trend towards surrendering personal moral responsibility as well. In short, being in prison tends to make one bad. Read Hayek.
Some have so forgotten the traditional virtues of Hiprocratic professionalism that they now see a medical license as just a business license that allows them to extract money from public coffers.
As is indicated by the comments above, some routinely submit falsified “invoices” in order to do so.
Actually the money isn’t much. Less than I could make in practice and many times less than I could pay pretending to practice while milking the medicaid/medicare cow. The special privileges are the opportunity to defend traditional standards a bit on the margins by reinforcing certain minimal standards of care and at least the appearance of professionalism–and uninterrupted sleep at night.
I would rather that the system were more rationally focused on finding the bad actors and monitoring them, and leaving the rest alone–but I didn’t write the rules of the prison–after all, I am only one of the prisoners. Of course if we were still a profession, then we would be self-policing, but that practically never happens.
anonymous 8:14 am:
I appreciate your candor, but feel you are doing the right thing for the wrong reasons, or maybe the wrong thing for the right reasons.
Your surveillance of other doctors is not for the greater good of the patients, or for the integrity of the medical profession, but simply to protect the pocketbook of the insurance companies.
Imagine what would happen if all of the physicians that lend credibility to insurance companies saw the light. No more medical directors. No more chart reviews. No more approval processes.
If you are not part of the solution then you are part of the problem.
A family practitioner
I don’t do it for insurance companies–I do it only for government programs. i once did it for an HMO but they got too piggy so I walked off–which didn’t slow them down one bit. They eventually ground to a halt a few years later when doctors and patients got too disgusted to deal with them anymore.
If every medical director or reviewing doctor walked off the job tomorrow, they would just go on with nurses, psychologists, social workers, chiropractor, pharmacists–whatever.
They would shut down tomorrow if all or even most treating physicians wouldn’t deal with them on their terms. On the government side, reviewers would disappear if the medical community would effectively self-police. I have had doctors ask me to shut down their quack fellow staff members–what ever happened to peer review at the hospital staff level? That is primarily the job of the medical staff.
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