Electronic health records (EHR) are a double-edged sword. They can reduce the time it takes physicians to document patient encounters, allow real-time access to medical records and promote legibility. But CMS and Medicare contractors are wary of classic EHR physician documentation shortcuts — cloning (cut and paste), macros and templates — and audits are bearing out their concerns.

Electronic health records (EHR) are a double-edged sword. They can reduce the time it takes physicians to document patient encounters, allow real-time access to medical records and promote legibility. But CMS and Medicare contractors are wary of classic EHR physician documentation shortcuts — cloning (cut and paste), macros and templates — and audits are bearing out their concerns.

“EHRs are a great invention as long as they are carefully used and reviewed,” said Kathleen Enniss, compliance analyst at UW Medicine Compliance, part of the University of Washington School of Medicine in Seattle, which includes three hospitals. “Each note should contain individualized data that supports the medical necessity of the visit or procedure.” When Enniss audited EHRs, she found problems stemming from use of documentation shortcuts.

There are three primary areas of EHR physician documentation shortcuts:

(1) Cloning (cutting and pasting): Physicians copy information from previous patient encounters (e.g., demographic, history of present illness, exam, medical decision making) and paste it in the current encounter.

(2) Templates: Physicians fill out templates for patient encounters that cover a lot of ground with a few key strokes. The review of systems is pre-filled with the term “negative” for each organ system. For positive answers, physicians must change “negative” to reflect the positive response given by the patient.

(3) Macros: Macros are a type of EHR shortcut that allows the entry of generous customized data quickly. Though initially CMS resisted the use of macros, the agency gave its approval for their use by teaching physicians (see Medicare Transmittal 811). With macros, teaching physicians, for instance, type in “.liv” to convey “liver exam,” which triggers a drop-down menu of choices for the next step.

The government obviously is encouraging (essentially mandating) the adoption of EHR systems, but CMS has expressed concerns about documentation shortcuts. Although the agency hasn’t issued any transmittals or other formal guidance on their use, there are “little blurbs here and there,” Enniss tells RMC.

For example, CMS has made a few things clear, including:

(1) Templates are meant to prompt documentation, “not do the bulk of it,” Enniss says.

(2) The sheer volume of documentation should not influence the selection of the visit code; “it’s a matter of quality, not quantity.”

(3) “Medical decision making is a cognitive process that’s hard to document with templates and macros.”

Medicare contractors have put out more explicit guidance on some aspects of EHR documentation shortcuts. Some Part B Medicare carriers, such as Trailblazer and Noridian Administrative Services, have published articles warning against cloning “because it’s hard to tell what documentation was provided for the current visit.”

Audit Sample: 10 Visits in 15 Months

Enniss audited the use of EHR shortcuts, such as cloning at University of Washington School of Medicine, to determine whether it was used excessively. “I was concerned with what I was seeing in these notes,” she says.

During the audit, Enniss focused on the repetitious use of copy and paste, as well as contradictions and inconsistences in the medical records. For example, an April 25 EHR note stated the patient was given a holter (cardiac) monitor and would need it until May 12. But the EHR note on May 23 used the exact same (not updated) language. “I continued with the patient note and went through September,” Enniss says. “The note still said the same thing” — that the patient would complete holter monitor evaluation by May 12. “It makes me wonder what else is in there that could cause a problem.”

Another problem with cloned notes is that even when they meet coding criteria, there may be a lack of medical necessity if nothing changes from visit to visit except a few words.

Contradictions Were Found

Enniss also identified contradictions. For example, a patient presents with abdominal pain, describing it as an eight on a pain scale of one to 10. But the physician’s EHR notes for the exam state the abdomen is benign. “It tells you the [documentation] doesn’t reflect the patient complaint,” she says. “The physician didn’t update [the EHR] since the last visit,” and may have pulled forward notes from the previous encounter.

Enniss defined her audit sample as all UW clinic providers who saw patients at least 10 times during the previous 15 months. “But you can also do all patients seen in the same day if you want to look at copy and paste from patient to patient,” says Ennis, who also spoke recently at the Health Care Compliance Assn. compliance institute in April. “Or you can audit inpatient notes and look at all the same patients over a period of time to see how much has changed.”

Next, Enniss defined the scope of the audit: to review each note and compare it to the previous and subsequent notes. Did providers update notes or copy and paste the whole enchilada even though patients had new complaints and circumstances?

She also compared notes from different providers. Sometimes notes can be copied from another source. “In our system, a provider can go to a resident’s note, copy part of it and paste it into their physical exam documentation, and there is no way to tell without going to the IT department and asking them to dissect it,” Enniss says.

For example, for a hospital patient, when a specialist’s note looks like it may have come from a resident, Enniss can ask IT for the name of the note’s originator “so I can determine when they have been cutting and pasting,” she says. “We have hospital settings that are under a lot of scrutiny and this is one of the things we know [Medicare auditors] are looking at.”

Multiple Problems Were Identified

While she was conducting the audit, Enniss also checked for provider compliance with Medicare signature requirements — legible signature, time, date and authentication. Medicare signature requirements are under intense scrutiny by Medicare contractors.

Here are her findings on the outpatient side:

(1) History of present illness (HPI) was repetitious instead of recording new information from patients.

(2) Review of system, or ROS (e.g., cardiac, circulatory, digestive) macros said “negative” even when HPI “held contradictory answers.”

(3) Exams seemed to be identical from visit to visit and didn’t always reflect the HPI or chief complaint.

(4) Medical decision making (i.e., assessment and plan) “was a problem that remained the same from visit to visit and contradicted the history and exam.”

(5) Contradictory information was carried forward over several dates of services, which sometimes causes inaccurate diagnosis codes.

To reduce the risk of problems around documentation shortcuts, Enniss recommends implementing best EHR practices. For example, develop macros that can be reviewed, amended, and reused and not prepopulated with ‘negative,’” she says. “Physicians should be able to adjust findings to reflect their patients’ actual status, and not be boxed into a corner of extremes (e.g., cardiac/no cardiac).

Reprinted from REPORT ON MEDICARE COMPLIANCE

By Nina Youngstrom, AIS Health Business Daily Managing Editor (nyoungstrom@aishealth.com)

Additional government news appears in Government News of the Week

Source: www.AISHealth.com, AIS’s HEALTH BUSINESS DAILY, Aug. 23, 2010.

Posted by permission of Atlantic Information Services, Inc.