Articles on Compliance Strategies

Compliance Risks Grow With Electronic Medical Record Systems

Reprinted from the May 28, 2007, issue of REPORT ON MEDICARE COMPLIANCE, the nation's leading source of news and strategic information on false claims, overpayments, compliance programs, billing errors and other Medicare compliance issues.

Physicians love electronic medical record (EMR) templates because they make documentation faster and easier, but abuses, such as cloning and "exploding" notes, are jeopardizing reimbursement and compliance, experts say. If too much information is replicated from one EMR to the next, there is little to distinguish patient encounters, and that undermines physician attempts to establish medical necessity — the foundation of Medicare reimbursement — and perhaps implicates quality of care.

While CMS has not taken a position on templates, the agency has conveyed that they are meant to prompt physician documentation, not do the lion's share of it. Medicare carriers, meanwhile, have been warning against cloning for years, saying claims supported by cloned documentation will be denied unless medical necessity is established independently. A cloned chart in isolation looks great, but line up 10 charts, and they're nearly identical — even if patients have presented at their physicians' offices for different reasons, experts say.

"The ability to have template-type documentation makes physicians more effective and efficient [and] is essential, but the inappropriate use of templates, such as cloning, is a problem," says compliance officer Holly Louie, who serves on a committee advising HHS on EMR standards and using EMR in fraud identification. "Certain government agencies are very concerned about cloned documentation," says Louie, who works for Practice Management Inc. in Boise, Idaho.

The perils of templates have become a hot topic because EMR systems generally are becoming more popular. At the same time, physicians are always struggling to comply with Medicare's 1995 or 1997 evaluation and management documentation guidelines. But prepopulated templates and cloning may be too easy a fix, experts say. "Anything that puts in clinical information independent of the provider is [a compliance risk]," says a hospital compliance officer, who asked not to be identified. "Cloning can work for elements of the history, but cannot and should not be used for the history of present illness, the exam or the medical decision-making portion," the compliance officer says.

Medicare carriers frown on the use of what they call default documentation. "Payers have a problem [with it] because they really cannot tell what kind of work is done in each encounter if the records are so similar," Louie says. Also, payers want the documentation to support medical necessity, but it's hard for physicians to document medical necessity because it's a cognitive process. "Medical records have to document and support the medical necessity of what you do. Carrying forth documentation that's not even relevant to what you did [through cloning or prepopulated templates] is not even eligible to receive payment because it's not medically necessary," she says. "It's not good for providers, and the government's increasingly aware of this. It's coming full circle now because EMR is getting so pervasive."

Carrier bulletins from across the country, including Cigna, Trailblazer and the carriers in Florida, Texas and Georgia, warned that cloned documentation wouldn't meet Medicare's medical-necessity standards and therefore wouldn't qualify for payment. For example, according to Trailblazer's Sept. 30, 2002, bulletin, "Medicare is concerned that defaulted documentation may cause a provider to overlook significant new findings. Medicare is also concerned that the provider's computerized documentation program defaults to a more extensive history and physical examination than is medically necessary to perform on a given day, and does not differentiate new findings and changes in a patient's condition."

Cigna Government Services states on its Web site that "'copied & pasted' and/or cloned documentation (as available in electronic medical records) that is not medically necessary should not be counted towards the level of service billed."

Disconnect Between EMR, Patient

Sometimes prepopulated templates and cloned records barely seem to describe the patient at all, Louie says. For example, a patient comes to see her doctor about a skin allergy, and the EMR for this visit is cut and pasted from the previous medical encounter. That means all the vital signs, history and physical, and review of systems are carried over from the patient before her with the intention of updating it. But everyone is busy, and the EMR isn't customized. Her chief complaint is skin allergy, so that gets documented in one part of the record, but the details don't trickle down, so the cloned medical record states "normal" under "skin" because the previous patient had no skin problems - even though the patient's chief complaint was skin allergy.

"They're falsifying if the cloned medical record says they did something, but they didn't do it" by cutting and pasting one chart into the subsequent patient's EMR, the hospital compliance officer states.

Things can get even more perilous with the use of exploding notes, the compliance officer says. Exploding notes or exploding macros means a simple checkoff of "normal" or "negative" prompts the documentation of a complete organ system exam.

For example, a physician checks off "normal" for the gastrointestinal (GI) system, and then a patient's chart automatically is full of other descriptors, such as "abdomen soft and non-tender, normal bowel sounds, not distended, organomegaly (e.g., liver not enlarged)," etc.

In other words, this kind of template takes over documentation for the physician, the hospital compliance officer says, leaving little room to choose the adjectives that fit the patient. Suppose the one thing the physician failed to do was listen to the patient's bowels with a stethoscope, and it turns out the patient's supposedly "normal" GI actually lacked bowel sounds? "The one thing the doctor didn't do comes back to bite him," with the situation compounded because the exploding macro states the patient had normal bowel sounds, which implies he used the stethoscope on the patient's belly, says the compliance officer. The risks are many - quality, malpractice, reimbursement and compliance.

Louie encourages physicians to customize medical records "to the greatest extent possible, even in a templated system, so it's obvious to [auditors] that they are not carbon-copy records," she says. Document the patient's chief complaint, which should carry through to the physical exam and the history, and that should support decision making and medical necessity.

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