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."