Tuesday, October 9, 2012

Outlawing Templated Notes in the Electronic Health Record

It was just a matter of time until this would happen.

Buried in the middle of this New York Times article on The Ups and Downs of Electronic Medical Records is the observation that a Medicare administrative contractor dubbed National Government Services has announced that it, on behalf of CMS, will "deny payment" for medical services that are documented in an electronic health record (EHR) using "cloned documentation."

The topic was covered more than 2 years ago by the DMCB here.  "Cloned documentation" is the widespread practice of copying, pasting past documentation in an EHR into the current encounter record to inflate the recorded patient evaluation to primarily justify a higher payment.  Thanks to this OIG report, the Feds have figured out that the true value proposition for an EHR is not "meaningful use" but wasteful abuse.

In addition to congratulating the Times for their crack cutting-edge reporting, the Disease Management Care Blog has a prediction....

1. The mere threat of payment denials and the possibility of sanctions will prompt health administrators everywhere to announce at medical staff meetings that "cloned" notes are verboten.

2. Until the "templated note" functionality is deleted in future EHR software updates, physicians will respond to this latest edict from their administrators in the traditional manner: they'll ignore it.

3.  Once the cloned note option is no longer available in the course of a patient encounter and physicians actually have to manually type out much of their encounter notes, patients will wonder why their docs are spending even MORE time staring at the computer screens and less time talking to them.

4. As clinic work flows get even more gummed up and waiting lists expand, outfits like National Government Services will announce that it will deny payment for documented medical services that are not provided in a timely manner. 

Silly you say?  Think again.

1 comment:

James said...

“…electronic records are vulnerable to crashes.” – This statement is from the link you provided. The statement is correct, but I think the medical person in charge of keeping their patients’ important documents won’t let that malfunction occur. It has been every company’s rule to create a backup of their important files to make sure that their files are still secured, and I think the person liable for this task will be responsible enough to follow this simple rule in case something went wrong.

James Guertin