EMR-Wars: Attack of the Clones

Cloning (Photo credit: borkweb)

Cloning (Photo credit: borkweb)

A warning-shot from Medicare has advised healthcare providers that “cloned” medical records notes will result in payment denials, and the Dept. of Health and Human Services stated that billing fraud will be “vigorously prosecuted”.

This is in response to recent news coverage noting that Electronic Medical Records* (EMRs) have made it easier to “upcode”; that is to bill a visit for a higher payment level than might be done without an EMR in use.

Healthcare gurus know that Electronic Medical Records  are one of the latest discussion points.  People cannot believe that something as complex as healthcare can be delivered safely and effectively with dead-tree media products.  It can and it is.    However, the march of technology is and should always be ever upward.  So EMRs will one day become ubiquitous.

But why are visits “upcoded” with an EMR?  It is because mandated documentation requirements – externally imposed on the profession by third party payors- result in long notes simply to check off bullet points required to receive a certain payment level.   Doing this electronically isn’t difficult with an EMR; but the clinical encounter and workflow take longer.  So naturally it makes sense to bill the visit at the highest level justified by the documentation and severity of the clinical problem.  That is not fraud.

The trouble with EMRs has been well-documented by many authors, including myself.  Remember that EMRs were not something the profession needed to make clinical functions smoother or easier.  If it did, the systems would be fast and easy to use and would enhance clinical workflow, much like most electronic systems do in purely commercial settings like restaurants.

Rather, this was an external imposition by those who purport to know how to fix healthcare.  Keep in mind that small, simple practices don’t need fancy electronic record systems, and entities that do such as large integrated institutions or big clinical practices, very often have them.

So what is a cloned note and how is it fraud?  Cloned notes are copies of earlier notes used on subsequent visits.  Is that really a big deal?  Most of the notes for a traditional medical practice that bills insurance contain a lot of information to satisfy billing points as noted above.    Most of it never changes from visit to visit, such as family history, past surgeries, etc.  So a simple solution is to have the patient check their prior information at each new visit and add anything new or changed.  The clinician then reviews this and makes alternations to the old note before finalizing the new note.  Why re-create all that material?

Fraud is something different.  That involves billing for things that were not done, or making up information.

The larger issue here is the inherent conflicts in third-party payor healthcare.   The clinician needs to satisfy the documentation requirements in order to receive any payment.  The required documentation is often more than what is really needed.  So clinicians look for ways to make this process easier.

As long as cloned notes are updated and reviewed before being finalized, they should be considered acceptable   Cloning is a good example of an unintended but predictable consequence of mandated use of cumbersome EMRs.

But confusing this with fraud is a different matter, and should not be allowed to lead to unwarranted disciplinary actions.

And I’ve never seen anyone clone a note with pen and paper

*-For simplicity the differences between Electronic Health Records (EHR) and EMR is ignored in this post.