By Emilie J DiChristina, MBA, CPHQ for PracticeFirst
As the July 2012 PracticeFirst Client Memo and Newsletter noted, the use of Electronic Health Records can be very helpful, but EMRs also offer a wide variety of shortcuts which can lead to a compliance audit for documentation. These audits will not just arise from CMS, but also from private payors and the NY State Medicaid Office of the Inspector General.
So what are the shortcuts that can lead to trouble?
First, BEWARE of the “copy and paste” function, which is also known as “cloning”.
The use of “copy and paste” allows past notes (or portions of notes) to be pulled forward into the documentation for a current visit. Obviously, it is a time saver when used appropriately, but it can result in a misrepresentation of the reason for the patient’s visit and cause fraudulent billing claims.
It may be appropriate to “copy and paste” the following: “Patient is a 42 year old well nourished woman here for an annual physical.” Unfortunately it is easy to start out your documentation with that statement (because of “cut and paste”) when in fact the woman was in your office for an acute problem such as fatigue. People who are not familiar with EMR, or who type poorly, or who are busy may forget to stop the “copy and paste” at “Patient is a 42 year old well nourished woman here for”…subsequently choosing the current presenting symptom to complete the statement.
As helpful as you and your staff may find the practice of “cut and paste” or “cloning” may be, carrying forward information without word for word review can inadvertently cause contradictions in a patient’s chief complaint documentation or history of present illness.
Obviously this is not only a compliance issue, but also poses a med-mal risk as previous complaints or symptoms in current documentation can lead to errors, including misinformed treatment and billing/coding.
Think this never happens? Do a bit of research in your professional journals where you will even find accounts of “clinical plagiarism” where physicians have cut and pasted large blocks of text, or even complete notes, from other physicians. The consequences for patients when this happens can be significant.
Once “cloning” becomes a habit, each record in which the individual provider or staff member documents is now suspect, from the medical malpractice viewpoint right through into the inability to prove that procedures and tests were done and reviewed, medications were modified based on correct lab work (e.g. Coumadin, antibiotics), and much more.
Next, beware of “Macros”. Macros represent the potential for significant efficiency in the EHR if all patients were unisex, and presenting with the same problem.
Basically, “macros”are templates of “standard” or “usual” review of systems, taking of a HPI, or description of a procedure. These became somewhat common during the use of dictation to save the provider and the transcriptionist time. The provider would dictate “use standard cardiac exam macro”, and the transcriptionist would push a button whereupon the words would fill in while the dictation continued.
Now, with many EHRs there is no transcriptionist, so the provider has these “macros” built in to drop down when a box is pushed. Imagine how a tired provider with bleary eyes can accidentally hit one macro above or below the one he or she wanted!
Here is an excellent example of how badly documentation can be badly messed up – it comes from Emergency Physicians Monthly in their May 6, 2011 edition:
Macros, whether dictated or from an EMR, may be quickly, inadvertently, and inappropriately invoked. The result can be more than just embarrassing. For example, a female patient who sustained some minor injuries from a fall obtained a copy of her ED medical record and wrote a letter complaining about multiple discrepancies between the documentation and what actually happened in the ED. The chart read as follows:
“KNEE EXAMINATION: The patient has full range of motion of the knee. There is no local swelling or tenderness. There is no instability with the medial or collateral lateral ligament stress. There is normal Lachman test with no instability. McMurray’s test is done with no locking or clicking & no significant pain. There are no effusions.”
In response to this, the patient wrote, “Not done at all. Had one been done, it would have been evident that I had multiple knee surgeries including a total knee replacement from the scars on my right knee.” The chart went on to say,
“There is normal external female genitalia & normal vaginal introitus & mucosa. There is no cervical motion tenderness or lesions. The uterus & adnexa have no masses or tenderness. There is no purulent vaginal discharge.”
The patient responded with, “Not done at all, nor would I expect it due to a fall landing on my shoulder. Also, I had a total hysterectomy in 1982. Therefore, I do not have a cervix, uterus, or ovaries. I am understandably upset about the inaccurate information concerning my physical exam and would not like to see my insurance company billed for things that were not done. Nor, do I want inaccurate information in my health record.”
A quick check with the doc confirmed a bad case of “documentation with brain-disengaged” syndrome. His correcting addendum included the following: “My normal template components were transcribed.” Fortunately for the doc, the patient directed her concerns to the EP group, rather than bringing what appeared to be a case of fraud to the attention of her insurer or federal authorities.
Finally, Re-consider the Use of Scribes. “Scribes” essentially are staff members that are in the room with the provider when he/she is performing exams, procedures, and tests for the purpose of documenting in the EHR and insuring prescriptions or tests are ordered electronically as stated by the provider.
Scribing, or authenticating notes made by another person, can be a fraudulent act if not clearly acknowledged by the provider for whom the scribe was scribing.
Scribing can be more risky and hard to detect in an EHR, even though scribing has long been in use on paper charts. The reason is simple, no handwriting to compare, so it is harder to track if the scribe made an error or if the provider made the error.
Another major risk of the EHR when scribes are used, is the fact that once the provider logs in to add any documentation, or simply to sign off on the order, the provider has now “over-written” the note. In essence, unless the provider checked everything line by line, double checked each decimal point in the prescriptions, etc., his or her access to the record now result in the provider erasing any way to check what, if anything, the scribe may have done incorrectly.
“Over-writing” in EHRs can also misrepresents who provided the service. This has ramifications for scope of care (unlicensed vs. licensed personnel) and for billing and compliance. By misrepresenting who provided the “scribed” service and then submitting that for billing, providers may both be violating their own license by allowing (or appearing to allow) unlicensed personnel to perform services, and committing fraud by signing that they performed a service done by another person (such as a HPI taken by a medical assistant).
Also, if a provider simply “over-writes” without making necessary checks and amendments, he/she may miss errors made inadvertently by themselves or their scribes. For example, two of the most common types of medication errors include prescribing or administering the wrong drug, and names of medication are confused because of similarities. Do you think it is possible that a scribe could confuse “Tramadol and Toradol”? Of course you can – that is why it is one of the most common mistakes!
The INAPPROPRIATE use of “copy & paste”/”cloning, macros, and scribes can place you at risk of complaints of billing fraud and of course medical negligence.Think this may be an overstatement?
You have to remember that as the provider of record for the patient, you are responsible for the contents of the medical record for any service you provide, So whether you (or someone else) pushed the wrong button, cloned too much, or entered the wrong diagnosis/medication, etc. – YOU are the one doing the explaining of why you did not commit fraud or medical negligence. (see the definitions of each below)
Fraud means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person (this includes anyone who does not insure that material cloned, scribed or entered by macro is an accurate representation of what he/she as the provider actually did).
Medical negligence occurs when a healthcare provider injures a patient by failing to provide a standard of care. Healthcare providers owe patients a certain standard of duty. When actions or lack of actions are done in a negligent manner (this includes failing to insure that material cloned, scribed or entered by macro is an accurate representation of what he/she as the provider actually saw, heard and prescribed) that results in injuries, the healthcare provider may be held liable for those injuries, including the medical treatments necessary to help correct the new injuries that have occurre