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AMA Raises Reimbursement Concerns Over EHR Workarounds

Physicians’ use of electronic health records may lead to denial of reimbursement for some services, the American Medical Association chair warned last week.

During a CMS listening session, AMA chair Steven Stack, MD, who is also a Lexington, KY emergency physician, said that some Medicare carriers have already issued rules that if patient charts look too similar, they will deny payment for them.

Stack says this is happening even when physicians are using EHR software appropriately and under threat of financial penalty if they do not use EHR software.

In essence, physicians “are being instructed de facto to reengineer non-value-added variation into their clinical notes,” Stack says. “This is an appalling Catch-22 for physicians.”

recent survey by American EHR Partners found continued physician dissatisfaction with EHRs.

Between 2010 and 2012, the percentage of doctors who would not recommend their EHR to a colleague increased from 24 percent to 39 percent. Approximately one third of the 4,279 physicians surveyed said they were very dissatisfied with their EHR, and that it is becoming more difficult to return to pre-EHR levels of productivity.

“Simply stated, many EHRs are not friendly to the user, and rather than improving physician efficiency, they are a widespread source of frustration,” Stack says.

Stack praised the general effort toward electronic health records. “Widespread adoption of EHRs, in combination with a progressive shift toward team-based care—both things which we would assert are good—are rapidly and dramatically changing clinician documentation,” Stack says.

Documenting a full clinical encounter in an EHR, however, “can be pure torment,” Stack told CMS officials. “The full chart doesn’t fit on a computer screen,” he says. “Each element is selected by a series of clicks, double clicks, or even triple clicks of the mouse.” Furthermore, “Hunting, clicking and scrolling just to complete a simple physical exam is a tedious, time-wasting experience,” he added.

In response, physicians have turned to three time-saving methods, each of which has the potential for abuse leading to the denial of payments that alarms Stack and the AMA.

The three methods – cut-and-paste, templates, and macros – can be logical and beneficial for static information, such as the date of an appendix removal, Stack says.

“Cut and paste becomes bad, and is appropriately criticized as cloning, when physicians reproduce information created by themselves or others, either without attribution or without attention to its accuracy,” Stack says.

“It is not appropriate for a clinician to copy another professional’s history verbatim and present it as if he had obtained it from the patient himself,” Stack says. “It is often appropriate, however, for a clinician to document that she has reviewed the note of another professional, and to summarize the key elements in her own note, with attribution to its source.”

Regardless of the frustrations associated with the EHRs, physicians, and other clinicians still have the obligation to review their own documentation to ensure that the information is accurate, Stack says. “EHRs can make this process infuriatingly difficult at times,” he says. “Even so, though it may not be fraud, glaring inaccuracies created by carrying forward prior notes with obvious errors are simply not acceptable.”

Many payers and compliance officials have long criticized inconsistencies and variation in physician documentation, but EHRs have shifted the criticism to one of overwhelming homogeny, Stack says.

“Even if the clinician accurately selects individual data points on a template, every single chart containing that documentation template will look essentially the same and make use of the exact same words,” Stack says. “In this case, it looks as though every clinician has plagiarized the words of every other clinician. In fact, many of our EHRs enable users to access templates and macros created by any user in the system.

If one physician has a particularly pithy, erudite, or precise way to describe a certain finding or condition, and saves it as a favorite, she may later find that her own words begin to appear in the notes created by other clinicians, who liked her descriptions so much, they adopted it themselves, Stack says.

The AMA urges the Office of National Coordinator to address EHR usability concerns raised by physicians, and to take “prompt action to add usability criteria to the EHR certification process,” Stack says.

He suggested ONC reconsider Stage 2 of Meaningful Use to allow more flexibility to providers to meet its requirements.

Scott Mace, for HealthLeaders Media , May 7, 2013

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