EMR macros and templates

[Guest guest]

This is from Emergency Physician Monthly. With more EMRs in EMS and already

having problems with medicare/medicaid, I would imagine EMS will also be

" investigated " . Please be careful how your providers use normal

templates/macros and auto narrative generators!

Macro Medicine

by , MD, JD on May 6, 2011

From Embarrassing Mistakes to OIG Fraud Investigations

" To err is human, but to really screw up takes a computer. "

When the Office of Inspector General (OIG) released its 2011 Workplan – a formal

announcement of the areas it plans to investigate – it boldly brought physicians

under increased scrutiny for fraud, based solely on what may be an unintended

consequence of the evolution of documentation technology. Specifically, in the

section titled, " Payments for Evaluation and Management Services, " the OIG wrote

that " Medicare contractors have noted an increased frequency of medical records

with identical documentation across services. We will also review multiple E&M

services for the same providers and beneficiaries to identify electronic health

records (EHR) documentation practices associated with potentially improper

payments. " The implications of this statement for emergency physicians are broad

and should be taken seriously. (download the Workplan at www.oig.hhs.gov).

Let's take a look at exactly why the OIG has taken an interest in the phenomenon

of " identical documentation. " How many ways are there to dictate a normal

cardiac exam? After dictating the normal exam a few thousand times, the words

flow out reflexively: " Heart: regular rate and rhythm without murmurs or

gallops. " How about the HPI of a patient with a sprained ankle? Even histories

become pretty rote: " Pt complains of right ankle pain after inversion injury. "

Documentation systems looking for efficiencies have taken advantage of dictated

or menu driven " macros. " So, when the physician instructs, " use my normal exam

macro, " the transcriptionist pops up the pre-formatted text, saving both the doc

and the transcriptionist time and effort. Templated systems take advantage of

the repetitive nature of much of what we do, reducing much of the required

documentation to a series of check boxes.

Now we have electronic medical records, which combine both the best and worst of

rote documentation, macros, and check boxes. Some of these EMRs require

physicians to click on boxes or menus; the EMR then spits out a chart of

pieced-together pre-formatted text (like the dictation " macros " ). Although these

are referred to as computer-generated narrative charts, the narrative is all too

often obscured by a plethora of time stamps, user ID initials and the awkward

juxtaposition of preformatted sentences or phrases. As a result, the end product

is a chart which takes even longer for a reader to figure out than for the doc

to create.

Macros, whether dictated or from an EMR, may be quickly, inadvertently, and

inappropriately invoked. The result can be more than just embarrassing. For

example, a female patient who sustained some minor injuries from a fall obtained

a copy of her ED medical record and wrote a letter complaining about multiple

discrepancies between the documentation and what actually happened in the ED.

The chart read as follows:

" KNEE EXAMINATION: The patient has full range of motion of the knee. There is no

local swelling or tenderness. There is no instability with the medial or

collateral lateral ligament stress. There is normal Lachman test with no

instability. McMurray's test is done with no locking or clicking & no

significant pain. There are no effusions. "

In response to this, the patient wrote, " Not done at all. Had one been done, it

would have been evident that I had multiple knee surgeries including a total

knee replacement from the scars on my right knee. " The chart went on to say,

" There is normal external female genitalia & normal vaginal introitus & mucosa.

There is no cervical motion tenderness or lesions. The uterus & adnexa have no

masses or tenderness. There is no purulent vaginal discharge. "

The patient responded with, " Not done at all, nor would I expect it due to a

fall landing on my shoulder. Also, I had a total hysterectomy in 1982.

Therefore, I do not have a cervix, uterus, or ovaries. I am understandably upset

about the inaccurate information concerning my physical exam and would not like

to see my insurance company billed for things that were not done. Nor, do I want

inaccurate information in my health record. "

A quick check with the doc confirmed a bad case of " documentation with

brain-disengaged " syndrome. His correcting addendum included the following: " My

normal template components were transcribed. " Fortunately for the doc, the

patient directed her concerns to the EP group, rather than bringing what

appeared to be a case of fraud to the attention of her insurer or federal

authorities.

The bottom line is that when we use macros, unavoidable uniformity from one

record to the next can raise the suspicion that the physician isn't really doing

the evaluation that has been documented. If the history and physical exam are

all the same in the last twenty sprained ankles (or chest pain patients,

etc...), the people who have to pay for the work you do may get the bright idea

that you're bending the truth. They may think your documentation is just as

fudged as the documentation of the complete GU exam in the patient who'd had a

total hysterectomy.

It would appear that the OIG wants to find out if physicians are merely

duplicating documentation from one patient to the next, billing for services

which may not actually have been provided. In other words, how often is

" identical documentation " the result of " my normal template components were

transcribed " ? It should come as no surprise to anyone that with the scramble to

adopt EMRs to obtain HITECH incentive monies, more and more ED records are

generated by EMR systems and more and more of them appear to have " identical

documentation across services. "

The irony is that with the right hand, the federal government is urging the

rapid adoption of EMRs, and with the left, the OIG and other fraud-fighting

agencies may be preparing to pounce on a natural by-product of those records as

fraud. Does the right hand know what the left is doing? Maybe not, but just

recall that under the misnamed Patient Protection and Affordable Care Act, an

additional $350M (that's on top of the annual budgetary allocation for fraud

enforcement) was allocated to identify and prosecute fraud, and it's a safe bet

that the intent is to get a whole lot more back in recoveries and penalties than

the newly allocated $350M.

Note that the OIG investigation is just that, an investigation, aimed at

determining if the " increased frequency of medical records with identical

documentation " is a fraud problem, or just an unintended and innocent

consequence of the evolution of medical records technology. Until the OIG

announces the results and conclusions of its investigation, we won't really know

how much liability exposure you may have from documentation systems which create

records which utilize pre-formatted verbiage.

So, what should you do to minimize your risk of fraud liability?

First, and most obviously, document what you do and don't document what you

don't do. That means using macros only when they accurately reflect the

evaluation that was actually done. Patients are more frequently taking advantage

of their right to obtain copies of their medical records, and you should expect

that if your documentation doesn't reflect what was actually done, sooner or

later, you're going to hear about it from a patient. That is, if you're lucky.

If you're not so lucky, you'll be hearing about it from a Medicare auditor, or

perhaps a federal prosecutor.

Second, whenever your documentation allows it, make sure there is some portion

of your documentation of the patient encounter which is individualized for that

patient, so that any subsequent reader (or auditor) would realize that the

documentation (a) is " nonidentical " and ( could only have been created by

someone who actually evaluated the patient.

Third, if your hospital is planning to implement a new EMR, try to get involved

in the planning process so that some kind of customization capability (ideally

add-on dictation, typically electronic voice recognition) will be included in

the final package. That way, you'll at least have a system that allows quick and

easy generation of customized and individualized reports, even if only for a

brief portion of your medical record documentation.

Sensible documentation accurately reflecting the care provided is essential for

compliance. Taking the short cut, in the form of macros, may seem to be a viable

option to improve efficiency, but not at the expense of inaccuracies, fraudulent

documentation and a painful investigation from the OIG.

Dr. is a physician and attorney who serves as General Counsel, Director of

Risk Management, and Compliance Officer for Emergency Medicine Physicians, based

in Canton, Ohio.