Transistorization is a fact of life on Earth. Over the last 500 years, concerns regarding tasks that were once seen as time-intensive, or were deemed dangerous or impossible due to limitations based on distance, have all but disappeared. The computers of the 1950s now fit in the palm of your hand and operate at twice the speed. Jules Verne wrote the novel Around The World In 80 Days in 1873, not realizing that in the future, we could do it by commercial airliner in about 48 hours.
Getting to this point in the Great Human Interchange wasn’t easy. Computer makers have come and gone, planes have crashed, Pintos have exploded, and don’t even get me started on the Yugo.
In the realm of our health care delivery system, we find ourselves on the brink of one such innovation (with the forceful assistance of government incentives) with the proliferation of electronic medical records (EMR). While the positives of such a system, with regard to portability, simplicity and legibility, holds great promise, the dangers of such a system are becoming apparent with regard to audit risk.
The term “cloning” has popped up in the world of chart auditing since the dawn of the EMR. In an attempt to shorten the training time involved with perfecting the use of an electronic record, physicians are becoming comfortable with one template for documenting patient visits. As a result, doctors have developed the dangerous habit of repeating the same portions of a medical record verbatim across multiple patients.
For a moment, I challenge the reader to think about this fact and juxtapose it with the audit landscape developing in front of us. It used to be that if an insurer wanted to review records on a given charge, the entity would request one record and judge it on its own merits.
This way of auditing is now the exception rather than the norm. In the RAC universe, if you are a solo practitioner, ten charts can be requested every 45 days. In addition, under the RAC statement of work, the contractors are allowed to use extrapolation methods once an error is uncovered. Apply these auditing trends to cloned documentation of services, and the repayments will add up at a rate that endangers the practice.
The one intangible during the implementation of an EMR is clinical judgment. There isn’t a medical record in existence that can accurately reflect clinical judgment in the absence of physician input. The moments that count for an EMR are in the beginning stages of use. An investment of time at the front end into building multiple templates based on patient condition will bring the peace of mind that comes from reduced audit risk. The unexpected bonus is that the provider will end up creating a medical record that will provide an actual record of clinical assessment, rather than a record with manufactured bullets full of facts that have been created to fit a narrative.
With the proliferation of technology comes an accompanying wad of useless information that is easily shared. Yet no information is more important than a patient’s medical records. One size does not and cannot fit all. The clinical and financial implications are simply too important to simplify a medical record to one template.
The RAConteur will not appear in this space next week, as I embark on my own version of an around-the-world tour by driving from Milwaukee to St. John’s, Newfoundland, Canada and back. Look for the next posting on Wednesday, August 10th.