Q. How do physicians view the implementation of electronic health records in their practices?

A. A survey conducted by the American College of Physicians and American EHR Partners evaluated data from a survey of 4,200 clinicians, revealing that 34 percent are “very dissatisfied” with the ability of EHR to decrease workload and 32 percent have not returned to the same level of productivity they had pre-implementation of EHR.

Q. What are some of the unintended consequences associated with EHR?

A. What appear to be attractive options with EHR (e.g., carry forward, auto-completion, comprehensive templates and macros for documentation) can result in inaccuracies and medically inappropriate services. Despite the best intentions by physicians to improve documentation, errors result, claims are overpaid and an audit could result. 

Q. What types of errors have been noted by regulators?

A. The Office of Inspector General is acutely aware of EHR documentation errors. The 2013 OIG Work Plan includes the following as a target for scrutiny1:

“We will determine the extent to which CMS made potentially inappropriate payments for E/M services in 2010 and the consistency of E/M medical review determinations. We will also review multiple E/M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments. Medicare contractors have noted an increased frequency of medical records with identical documentation across services. Medicare requires providers to select the code for the service on the basis of the content of the service and have documentation to support the level of service reported.”

It has also been shown that EHR users have an increased utilization of level 4 and 5 Evaluation and Management services due to robust charting with much more information in the history and exam2; prepayment audits of CPT 99204 have been initiated by some Medicare Administrative Contractors.3

Q. Is it necessary to populate every exam element at each encounter documented on the EHR?

A. No. When learning how to use the EHR, users learn to populate all of the cells, so it appears that every exam is comprehensive. To speed the process, some EHR programs pre-populate the eye exam with “normal” findings, which the physician modifies with pertinent positives where abnormalities are identified. This technique, known as charting by exception, can lead to errors when some parts of the eye were not examined, but presumed to be normal. In addition, if every exam appears to be comprehensive, there is doubt that the physician did the work and that it was necessary to do it all on each encounter. Best practices utilize templates with exam elements and complete only those elements that are pertinent to the patient’s chief complaint and associated findings.

Q. Do macros—long, detailed notes triggered by a single word or keystroke, placing information in the patient medical record about a discussion related to a specific disease or treatment—present any issues?

A. They can. Although they’re comprehensive in nature, it is unrealistic to believe that this amount of information is shared with each patient diagnosed with a particular condition. This documentation may cause an audit risk—as described above—but also represents a risk management concern related to the quality of care and informed consent.

Q. Are there any concerns with the copy-paste or copy-forward functions that are available in some EHR programs?

A. Yes. Copy-paste or copy-forward is an attractive feature for EHR users because it speeds charting, but it does create the potential for numerous problems. This approach creates “cloned” notes. When used indiscriminately, the integrity of the medical record is doubtful because chart notes on successive records are identical. The potential for mistakes is also very high with this tool. It is best to minimize use of copy features, and ensure that any copied notations are edited with new information. If no new information exists, verify every copied notation.

Q. Can corrections be made in EHRs? 

A. There are several different types of “corrections” that can be made to an EHR. A correction is a change of the information in an old entry, after it is closed, to fix inaccuracy. Significantly, the old information must not be destroyed. The correction should stand out, be separately dated and time stamped, and individually signed. Practices should develop a policy as to who has the authority to “unlock” a record for this purpose. The privilege should be restricted to a small number of individuals and used sparingly.

An amendment is a note added to an old entry, after it is closed, to clarify the record. It should stand out, be separately dated and time stamped, and individually signed. An addendum is a new entry, with a new date/time and provider signature, that contains a separate notation that corrects or amplifies the prior note. The old entry is not re-opened, thereby avoiding criticism of altered records.  

Q. Has the Centers for Medicare & Medicaid Services published any guidance regarding the proper procedure for correcting errors found during reviews of EHRs?

A. Yes. In December 2012, CMS updated the Medicare Program Integrity Manual, Chapter 3 – Verifying Potential Errors and Taking Corrective Actions section – Amendments, Corrections and Delayed Entries in Medical Documentation in Transmittal 442, effective January 8, 2013. The information applies to those conducting audits and reminds them to consider the recordkeeping principles when conducting a review. An excerpt4 states:.

“Regardless of whether a documentation submission originates from a paper record or an electronic health record, documents submitted to MACs, CERT, Recovery Auditors, and ZPICs containing amendments, corrections or addenda must:
1. Clearly and permanently identify any amendment, correction or delayed entry as such, and
2. Clearly indicate the date and author of any amendment, correction or delayed entry, and
3. Not delete but instead clearly identify all original content.”
Additionally, records that have been sourced from electronic systems that “contain corrections or amendments, as well as delayed entries, must:

a. Distinctly identify any amendment, correction or delayed entry, and
b. Provide a reliable means to clearly identify the original content, the modified content, and the date and authorship of each modification of the record.”  REVIEW

Ms. McCune is vice pres­ident of the Cor­coran Con­sult­ing Group. Con­tact her at DMcCune@corcoranccg.com.

1. Office of the Inspector General. Office of the Inspector General Work Plan Fiscal Year 2013. https://oig.hhs.gov/reports-and-publications/archives/workplan/2013/Work-Plan-2013.pdf.
2. Office of the Inspector General, Coding Trends of Medicare Evaluation and Management Services. May 2012. https://oig.hhs.gov/oei/reports/oei-04-10-00180.pdf.
3. Palmetto GBA. http://www.palmettogba.com/palmetto/providers.nsf/DocsCat
4. Centers for Medicare and Medicaid Servicea. CMS Manual System. http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R442PI.pdf.