Regardless of the frustrations associated with the EHRs, physicians, and other clinicians still have the obligation to review their own documentation to ensure that the information is accurate, Stack says. "EHRs can make this process infuriatingly difficult at times," he says. "Even so, though it may not be fraud, glaring inaccuracies created by carrying forward prior notes with obvious errors are simply not acceptable."
Many payers and compliance officials have long criticized inconsistencies and variation in physician documentation, but EHRs have shifted the criticism to one of overwhelming homogeny, Stack says.
"Even if the clinician accurately selects individual data points on a template, every single chart containing that documentation template will look essentially the same and make use of the exact same words," Stack says. "In this case, it looks as though every clinician has plagiarized the words of every other clinician. In fact, many of our EHRs enable users to access templates and macros created by any user in the system.
If one physician has a particularly pithy, erudite, or precise way to describe a certain finding or condition, and saves it as a favorite, she may later find that her own words begin to appear in the notes created by other clinicians, who liked her descriptions so much, they adopted it themselves, Stack says.