Audits of electronic charts have revealed three "classic EHR physician documentation shortcuts" (as if EHRs could ever be called "classic"), according to AIS Health, which reported on a compliance review at the University of Washington School of Medicine. Physicians tend to copy and paste data--a practice sometimes called "cloning"--to create templates for common observations and set up macros to trigger decision trees, the review found.
"EHRs are a great invention as long as they are carefully used and reviewed," Kathleen Enniss, an analyst in UW Medicine's compliance department, tells AIS Health. "Each note should contain individualized data that supports the medical necessity of the visit or procedure." But when a note didn't, she tended to find at least one of the types of shortcuts responsible for the error or oversight.
With the federal EHR incentive program looming, CMS hasn't formally commented on charting shortcuts, but Ennis says the Medicare and Medicaid agency has been fairly clear that: templates should prompt documentation, not actually produce most of the note; the volume of documentation shouldn't influence coding; and clinical notes should reflect the physician's decision-making process.
Ennis found that sometimes it's hard to determine which documentation correlates with the most recent encounter, and she discovered contradictions in many records. In one case, for example, the record said a patient rated abdominal pain as an eight on a scale of one to 10, but the physician recorded the patient's condition as benign.
"It tells you the [documentation] doesn't reflect the patient complaint," according to Ennis. "The physician didn't update [the EHR] since the last visit," and likely copied and pasted old notes.
For additional information:
- take a look at this AIS Health story