AMA Raises Reimbursement Concerns Over EHR Workarounds

Scott Mace, for HealthLeaders Media , May 7, 2013

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.

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1 comments on "AMA Raises Reimbursement Concerns Over EHR Workarounds"

Dr Bones (5/7/2013 at 5:27 PM)
Perhaps providers who work in small practices or those that are using the "free EHR"s have an inability to document a free form note but the majority of large EHR's have this capability. You can even dictate the history and physical and or the clinical notes and have it blown into the chart. It sounds like those practices that went the "cheap" way and didn't invest in any workflow redesign or pay for some consulting time are tripping up but this is the minority.




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