Improperly using your EHR turns a powerful tool into a liability

The percentage of office-based providers utilizing EHRs in their practice has jumped from 20% in 2004 to 87% in 2015. With almost nine out of every 10 providers utilizing some form of EHR, it’s easy to predict that they’re here to stay.

But has it proved to be an efficient, time-saving wonder, or is it a time-sucking, frustrating and sometimes even dangerous tool? The pros and cons for using EHRs goes on and on, and sometimes they overlap. While EHRs were developed to be efficient and provider-friendly, many will tell you EHR use has increased their workload and daily frustrations.

The goal was admirable: Create a well-connected, effective and efficient healthcare system that would reduce waste, increase patient satisfaction and improve outcomes. Are we there yet? From this auditor’s perspective, we have a ways to go.

Physician Quality Reporting System, Meaningful Use, Merit-Based Incentive Payment System and alternate payment models continue to keep us on our toes creating new rules, new requirements, new reporting guidelines and daunting tasks for providers and office staff. This is all well and good, and yes, required. But so is complying with quality medical record documentation standards. Medical record documentation must be accurate, complete, relevant and timely. Does your documentation meet these standards? Has your documentation taken a back seat to all the other important initiatives? Have creative shortcuts such as auto-fill templates, cut and paste or cloning one record to another put your records at risk for poor quality? Simple errors such as information gaps and typos can call your documentation and your care of the patient into question.

As an auditor, I have followed the adage “If it isn’t in the chart, it didn’t happen,” but sometimes sorting through volumes of EHR documentation has me asking, “It’s in the chart. Did it happen?”

It’s crucial to have documentation policies in place that address the EHR and its functions, and to outline areas of inappropriate use that can increase your risk for payment denial, patient dissatisfaction, legal woes and more. 

As you navigate the technical capabilities of your practice’s EHR, consider the following:

• Avoid auto-fill templates, especially if you don’t review them for errors or miscommunication, or don’t update them after every encounter. Auto-populated histories or review of systems or examinations that are not relevant to the presenting problem(s) or contradict information can also call an encounter into question. Do you ever see comments such as, “Healthy 1 ½ year old, denies tobacco abuse,” or “Patient presenting for severe exacerbation of asthma but ROS: denies asthma,” or “George is a 37-year-old male and she presents today.”
• Avoid overdocumentation. Do not insert false or irrelevant documentation to create the appearance of support for billing higher-level services. Populating extensive documentation with a click of a button may be inaccurate by suggesting the provider performed more comprehensive services than were rendered.
• Use copy and paste appropriately. This time-saving feature, allowing the provider to copy text and data from previous notes into a new note, creates a deluge of repeated and unnecessary information, and possibly may associate the documentation with improper payments.
• Be careful with cloning and other documentation “fluff.” Cloning — wording each medical record entry exactly like the previous entries or very similar to the previous entries — could lead to inflated, duplicated or potentially fraudulent claims. The medical record must have some difference in documentation from one encounter to the next.
• Review before signing. Perhaps, above all, review your completed note before signing. Once signed, corrected information must be documented as an amended medical record bearing the current date of the correction and the signature of the person making the addition or change. This is perhaps the most important thing a provider can do. Reviewing the record for accuracy before signing can give the provider the chance to make crucial corrections. A provider’s signature authenticates the validity of the record, so always make sure your documentation is signature-worthy.

Don’t get me wrong, I am not opposed to the implementation of EHRs in provider practices. They have many benefits when implemented and used properly, including improved patient safety, safer prescribing, quicker access to information and better data. Poor, inaccurate or incomplete charting could result in a malpractice claim, denial of reimbursement and, worst of all, possible injury to the patient. Providers are caught between a rock and a hard place, being scrutinized by the very systems that incentivize them for EHR use.

It’s crucial to have documentation policies in place that address the EHR and its functions and to outline areas of inappropriate use that can increase your risk for payment denial, patient dissatisfaction, legal woes and more. Don’t let your documentation be a liability.