Ineffective policies from numerous key organizations have contributed to widespread EHR compliance problems.
Well-intended physicians are being victimized when audits reveal their EHRs have allowed non-compliant claims.
Audited practices have been fined between $50,000 and $175,000 per physician for their inadvertent infractions.
Today's political and economic environment has focused a spotlight on healthcare reform and the promotion of health information
technology in particular. The Obama administration has promised to invest $10 billion per year over the next five years on
HIT, including electronic health records. Senator Max Baucus, chairman of the Senate Finance Committee, says HIT represents
"the beginning of healthcare reform and a key part of the economic recovery."
The Centers for Medicare & Medicaid Services (CMS) is also exerting increasing pressure on physicians to purchase HIT: financial
incentives for using electronic prescribing through 2013 and rising penalties to practices that fail to employ this technology
starting in 2012. The administration's stimulus package provides incentives for implementing and using certified EHR systems,
while those practices that don't adopt these systems by 2014 will receive reductions in reimbursement.
Health policy advocates justifiably point to a myriad of potential benefits that should result from the widespread implementation
of EHRs, from safe storage of health information to electronic sharing of clinical information. The knowledge shared through
this access to patients' medical data promises to improve patient safety and reduce costs associated with duplicate and/or
unnecessary tests and treatments. Electronic prescribing further promises to reduce medication errors, ranging from drug interactions
to misinterpreted handwriting.
Most physicians who introduce EHR systems into their practices seek promised advantages for enhancing quality care and patient
safety through the systems' touted data storage and retrieval characteristics. Electronic records offer immediate access to
patients' documents and data.
Likewise, most physicians include among their highest priorities the goal of compliant evaluation and management (E/M) coding.
Physicians believe they have a right to expect that these sophisticated and costly systems will ensure that they achieve compliant
documentation and coding, thereby "making any E/M problems go away."
However, something has gone awry to create an environment that leaves well-intended physicians victimized when government
audits reveal their software systems have allowed—even facilitated—submission of non-compliant and potentially fraudulent claims for E/M services. In the midst of increasing storm warnings
of non-compliant designs, physicians are increasingly vulnerable to severe financial penalties.
WHO BROUGHT THESE STORM ELEMENTS TOGETHER?
This devastating storm has been developing for many years, often bolstered by an unintended lack of effective policies from
several organizations that should have the best interests of physicians, patients, and the healthcare system at their core—organizations
such as CMS, the Certification Commission for Healthcare Information Technology (CCHIT), and the U.S. Department of Health
and Human Services (HHS), as well as EHR software vendors and physician training institutions (for more information).
I have personally been an expert witness in 5 malpractice case in two years caused directly by EHR's. The Veterans Agency EHR,touted by many as one of the top systems was involved in 2 of them. I counted 1012 pages of template heavy notes in one simple 8 month long chart and 157 times that this patient was supposedly screened for PTSD. Who are they kidding? EHR's are for data mining by cost cutting cynics and have little to do with patient care. Show me the prospective studies that document significant improvement in outcomes when EHR's are implemented. If duplication is such a big problem why doesn't CMS have a web-based solution? Oh sorry, then a government mandate would have to be paid for by government.
Randall Riley, M.D., RPh / Carmel, IN, UNITED STATES
Posted Apr 04 2009 09:36AM
I find this article to be no different than those which have been published for years regarding the use of EMRs. The issue of overcoding was addressed in an article in the AMA News a few years back where a fiscally healthy insurance company was trying to create a hybrid code between a level 3 and level 4 and pay an in between reimbursement rate. The group calculated that it would lose around $60K a year as a result. After their charts were audited, it was found that they were compliant and entitled to the level 4 coded charts but the hybrid code paid less than the level 4 reimbursement. While I am not advocating committing fraud, I think we need to redefine what is and is not fraud. Physicians need to be given a system for coding that is simple and to the point. After all, we are dealing with people's health, not flipping hamburgers. To state that billing at a particular level was inappropriate, what do we really mean? Who is to say that a service is "necessary?" If we do not provide services, we are accused of negligence if the patient suffers harm, and if we provide services we are accused of padding the bill.
Randall Riley, M.D., RPh / Carmel, IN, UNITED STATES
Posted Apr 04 2009 09:37AM
How do we survive in a house-divided-against-itself atmosphere? What is” fair” reimbursement? Can my paper boy discern what is best for my patients any better than I? If so, then let an uneducated, untrained person take care of the sick and ailing and comfort the distressed mother, daughter and mentally ill person at no charge. Many things that we do cannot be quantified, but that does not mean that we are not entitled to be paid well for a hard day's work. After all, there are plenty of people on the government payrolls who have very little accountablity, but receive benefits from the taxpayer including numerous paid holidays, health insurance coverage and retirement protection. Why not give the PCP his or her due rather that looking for more ways to indict an over-worked and stressed out provider of health care. Most physicians give a considerable amount of their time and effort without question or charge in the name of patient care and we are not all trying to bilk the system for every penny we can get. Studies have proved that the average physician will undercode for services. It is the complex billing and coding system which lends itself to creating an atmosphere of "fraud."
Randall Riley, M.D., RPh / Carmel, IN, UNITED STATES
Posted Apr 04 2009 09:40AM
EMRs are not the problem or the solution, they are simply tools. It is obvious that the tools are designed by programmers and not physicians nor billing experts or this would not be happening. A recent editorial in the Wall Street Journal has even pointed out that the myth of the savings and benefits of EMRs is just that. A few Harvard physicians have studied this matter extensively, and we are nowhere near getting it right. The article points out the fact that computers in the financial industry are great since money is a more or less one dimensional problem...simple math. Taking care of humans is the most rewarding, but perplexing challenge, and to think that an EMR record truly reflects the complex cognitive process which occurs with each encounter is ludicrous to say the least. Don't shoot the messenger who uses the EMR. It is our short-sighted and ill-informed, so-called goverment which is and has been, and will forever be pressuring the profession to move in this direction, not for patient safety, but to prove that all doctors are thieves and crooks and this is one sure way to prove it in their corrupt minds.
solofamilydoc / chico, CA, UNITED STATES
Posted Apr 04 2009 11:46AM
Can't afford an EMR, and at this point I don't think the bugs are out of the systems enough to trust my patient's health records or my livelihood to one. The hassle factor of Medicare will soon lead me to eliminate this insurance from my practice completely. The shortage of primary care physicians in my area has my practice bulging at the seams. As much as I love my old folks, I frankly can't afford to keep them.
Fernando Ortiz / Corpus Christi, TX, UNITED STATES
Posted Apr 04 2009 03:49PM
Sure , it may create an environment that allow and , as you said "facilitate" submission of non-compliant and potentially fraudulent claims for E/M services .But remember that a well programmed system handled by well trained office personnel will minimized mistakes . Besides, government will accuse a Medical Provider of fraud only after documented pattern of "mistakes" or inaccurate claims .
R Pafford / Cedar Rapids, IA, UNITED STATES
Posted Apr 05 2009 12:46PM
My partners have frequently warned me to document less so that we do not spend 2 extra hours a day documenting the content of out patients' conversations with us. Their words are deemed superfluous to the goal of a good note. Can you imagine me defending myself in a court room with the horridly templated notes produced by the EHR we have already spent $14 million dollars on. Debacle is a word that comes to my mind. I want out of this litigious mess. By the way, I WAS trained in the use of EMR as a resident. And, I'm more computer and software savvy than 99% of physicians out there. I write code as well. The emperor is naked! RGP
Donald W. Simborg, MD / Nevada City, CA, UNITED STATES
Posted Apr 09 2009 07:48PM
The authors of this article have made the correct diagnosis of the EHR problem, but, in my view, have recommended the wrong treatment. As the Chairman of the expert panel responsible for the HHS report quoted in the article, I agree that EHR systems provide tools that are frequently misused intentionally and unintentionally to provide documentation that is inappropriate, sometimes fraudulent and often clinically unhelpful and even harmful. The solution, however, to employ compliance experts to help evaluate systems to insure they contain no potentially non-compliant functionality is self-serving and impossible to do. Any EHR system can and will be used to produce clinically unnecessary levels of documentation as long as physicians are paid according to what they document rather than for the outcomes they produce.
David Walker / The Woodlands, TX, UNITED STATES
Posted Apr 14 2009 09:36AM
I agree with both of Dr. Simborg's comments regarding first the self-serving nature of this review and second the usage of the EHR as a tool which will be utilized to produce documentation so long as documentation is the driver for payment. Additionally, I would challenge the authors to define how the EHR might go about determining the medical necessity of the situation. I have developed EMR/EHRs for 15 years, and while this is a crucial point, it is the requirement of the physician, NOT the EHR. We have employed a statistical algorithm to determine if the patient is outside of the expected level of service and provide the physician a reminder to evaluate the medical necessity, but short of that, I see no way that the EHR can take on a bigger burden for this key point.
carmen t. garza / san antonio, TX, UNITED STATES
Posted Apr 14 2009 11:07PM
As a Pediatrician that works in a small group practice I find that EHR has not been designed to bring clarity or effectiveness in what really was done at the actual medical visit. I receive EMR from other practices that have 4 to 5 pages of generic EHR form letter for a simple ear infection. First it no longer conveys immediately a sense of scanning the SOAP method of the medical visit and next it does not put emphasis on what is most important. I beleive it will not improve patient safety. What oher country has demonstrated that it is helpful, cost effective and improves medical care and safety? If the EHR was developed to improve a method for payment by insurance companies this was developed without enough homework and needs to be refined alot before implementing it nationally and forcing doctors to pay to be required to use it. Let us learn from the experiences of other companies mistakes before we waste healthcare dollars on another new technology that subscribes to replace what can not be replaced--- a hard working dedicated doctor that writes a good SOAP to treat and improve the lives of his patients, who researches about their condition late at night, that calls the patient the next morning for follow ups and still answers phone calls at night because he cares.
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Posted Apr 03 2009 08:33PM
