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Technology Trap: When EMR Software

Does So Much lt Begins to Resemble Fraud

Electronic Medical Records (EMR) the question of whether the physician Services, Office of predefined answers, lim-
software functions have very practical could prove in any way that he was Inspector General (HHS- ited space to enter infor-
benefits and are increasingly required even there that day. OIG) indicated that due mation, etc. CMS dis-
for reimbursement purposes. The pur- While the accusation was in many to the growing problem courages the use of such
pose of technology is to create efficien- ways silly, the premise is one that can of cloning, its staff would templates."
cy and software aids a physician by be problematic, In fact, regulatory be paying close attention The recording of
ensuring a note is complete for treat- authorities have cautioned providers to EHR cloning. In 2016, patient notes and chart-
ment purposes and contains all the about several EMR software related a cardiologist group in BY BERNARD M. ing is one of the less
information required to make a claim fraud issues. One such issue is what New Jersey settled false CASSIDY enjoyable parts of prac-
valid and payable. However, a side auditors call "cloning." This is the prac- claims allegations with ticing. Particularly in
effect of the efficiency of such software tice of copying portions of notes from CMS for $422,000 which included an hospitals, harried physicians fall
is that it can generate records so similar one patient visit for use in another. allegation of cloning of patient behind. In Florida, at a recent Board of
from visit to visit and patient to patient There is nothing wrong with carrying encounter notes. Medicine meeting, a physician was dis-
that the records can appear fabricated. information forward from the initial or Another issue involves templates, ciplined after being reported to the
A typed clean looking note looks prior office visit that can illuminate the ENIR software uses templates to create Board by his own employer, a hospital,
more professional and avoids errors in rationale for treatment on a given visit the form and structure of a medical for chronic failure to keep up with
interpretation; however, in some ways a and, for billing purposes, justify the use record. With respect to SOAP notes, records. Software, with the efficiencies
handwritten progress note, even in of one code over another by reinforcing templates can fill in portions of a note created by copy and paste and fill in
potentially indecipherable physician the complexity of the interaction. using terms that are commonly used in templates, makes life much easier in
handwriting, can carry an authenticity However, this becomes a problem when diagnosis and treatment. In practices that regard but physicians should be
lacking in a computer generated record. the copied information is virtually all that are specialized or treat specific cognizant of when the software is too
In a recent case, a client physician was that appears in a note. CMS, in address- types of medical conditions; the notes, efficient and the notes start to look very
being questioned about his records and ing this issue, has indicated "The med- spread across not only the patient file repetitive. Charted patient encounters
the investigator focused on a particular ical record must contain documenta- but all of the practice records, begin to should have some originality to make
day and questioned why, record after tion showing the differences and the look very familiar, and at times, suspi- sure the world can tell the physician
record, for patients large and small, dif- needs of the patient for each visit or cious. The Medicare Program Integrity was actually there that day.
ferent genders and ages, all had nearly encounter. Simply changing the date on Manual specifically addresses tem-
the same words and phrases in the the EHR without reflecting what plates, and cautions physicians, "Some Bernard M. Cassidy, Partner, Lubell
progress notes. The obvious answer, occurred during the actual visit is not templates provide limited options Rosen, LLC, can be reached at
that the EMR software was designed to acceptable." Beginning in 2013, the and/or space for the collection of infor- 954-880-9500 or
aid in the generation of the notes, led to U.S. Depart ment of Health and Human mation such as by using "check boxes," bmc@lubellrosen.com

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4 June 2017 southfloridahospitalnews.com South Florida Hospital News