The Metastasizing Complexity of Templated Exam Notes

The Metastasizing ComplexityThe problems associated with templated exam notes have been well documented. From the amount of time it takes to build the notes by entering every piece of data via pointing and clicking, to the sheer length of the output that makes it hard for physicians to find the information they need, to the challenges related to upcoding and cloning (factors that the government is actively investigating), templated notes have been tolerated as a necessary evil associated with EHRs. But there are better ways to capture, exchange, and analyze discrete clinical data with precision, and without adversely affecting physician productivity.

As government programs rapidly evolve, and the number of such programs increases, the need to capture and analyze data will change and grow—think: new stages of meaningful use, PQRS, and the impending switch to ICD-10. An interview with orthopaedic surgeon Scott W. Trenhaile, M.D. in AAOS Now illustrates the increasing template-related burdens associated with ICD-10, just as an example. “We’ve spent a considerable amount of time on templating and are adjusting our templates to address those issues. . . . We’re changing the EMR templates to ensure that ICD-10 issues are covered. Answering certain questions in certain ways opens other templates so we have the information needed for ICD-10 coding.”

Just this past week, the number of anti-template commentaries published in the media has exploded.

  • The problem was aptly described as “note bloat” in a recent presentation to attendees of CHIME’s CIO forum, where the problems associated with typical EHR documentation of a patient exam were lamented.
  • A recent survey conducted by the American Medical Association and reported by the RAND Corporation cited the prominent concern among physicians that EHR technology “requires physicians to spend too much time performing clerical work and degrades the accuracy of medical records by encouraging template-generated notes.”
  • Bill Cayley, Jr., M.D., a family-medicine physician, blogged, “With the increasing use of electronic medical records (EMRs) and their ever-so-helpful templates, smart sets, and forms for capturing information needed to support billing and guide protocols, I fear we are losing the narrative forest for the well-documented trees.” He goes on to say, “Far too often, doctors are being forced to re-gather the entire history with the patient themselves, because prior documentation fails to provide the nuance needed to understand what happened during the last visit.”

If physicians are struggling with templated notes now, their problems are bound to be exacerbated as EHRs layer more and more levels of complexity onto already bloated platforms to try to keep up with the government’s voracious appetite for data.

Physicians need nimble and flexible data platforms to support the data-capture needed to identify and reward quality of care while maintaining physician productivity. The metastasizing complexity of the templated exam note can only lead to its demise.

Audit Risk: EHR Coding, Cloning, and Templated Notes

Audit Risk: EHR Coding, Cloning, and Templated NotesPhysicians beware: CMS recently expanded RAC audits (Recovery Audit Contractors) to include office visit (E&M) claims, with the goal of identifying inflated coding and aggressively pursuing fraud and abuse. A recent New York Times article, “Medicare Bills Rise as Records Turn Electronic”, alleged that “EHRs may be contributing to higher Medicare costs because they make it easier to bill more for services.” This is a natural outgrowth of the pre-meaningful use origins of many EHRs—they were typically designed to create a clinical note that would maximize reimbursement. The point-and-click, templated notes of many EHRs will also be subject to intense scrutiny—because the notes often include copied and pasted text and omit the nuanced information that is critical to truly meaningful documentation.

In a sternly worded letter to hospital and medical association executives on September 24, HHS Secretary Kathleen Sebelius and Attorney General Eric Holder warned that they “will not tolerate health care fraud” and will take steps “to ensure payment accuracy.” They expressed serious concerns that some providers are misusing EHRs to increase reimbursement by cloning medical record documentation and by upcoding visits.

This new focus on auditing E&M coding was spurred by the findings of a report by the OIG (Office of the Inspector General) issued in May 2012, “Coding Trends of Medicare Evaluation and Management Services.” Over the last 10 years, physicians have increased their billing of higher-level E&M codes and reduced their billing of lower-level codes. Therefore, the OIG recommended that CMS have its contractors review physicians’ billings for E&M services and that they review—for appropriate action—those physicians who bill higher-level codes.

One of Medicare’s administrative contractors, (National Government Services), recently announced that it will not accept cloned documentation. “Cloned documentation will be considered misrepresentation of the medical necessity requirement for coverage of services due to the lack of specific individual information for each unique patient. Identification of this type of documentation will lead to denial of services for lack of medical necessity and the recoupment of all overpayments.”

These audits pose a significant risk since auditors are paid based on the amount they recover from providers.