AMA Raises Reimbursement Concerns Over EHR Workarounds

Physicians' use of electronic health records may lead to denial of reimbursement for some services, the American Medical Association chair warned last week.

During a CMS listening session, AMA chair Steven Stack, MD, who is also a Lexington, KY emergency physician, said that some Medicare carriers have already issued rules that if patient charts look too similar, they will deny payment for them.

Stack says this is happening even when physicians are using EHR software appropriately and under threat of financial penalty if they do not use EHR software.

In essence, physicians "are being instructed de facto to reengineer non-value-added variation into their clinical notes," Stack says. "This is an appalling Catch-22 for physicians."

A recent survey by American EHR Partners found continued physician dissatisfaction with EHRs.

Between 2010 and 2012, the percentage of doctors who would not recommend their EHR to a colleague increased from 24 percent to 39 percent. Approximately one third of the 4,279 physicians surveyed said they were very dissatisfied with their EHR, and that it is becoming more difficult to return to pre-EHR levels of productivity.

"Simply stated, many EHRs are not friendly to the user, and rather than improving physician efficiency, they are a widespread source of frustration," Stack says.

Stack praised the general effort toward electronic health records. "Widespread adoption of EHRs, in combination with a progressive shift toward team-based care—both things which we would assert are good—are rapidly and dramatically changing clinician documentation," Stack says.

Documenting a full clinical encounter in an EHR, however, "can be pure torment," Stack told CMS officials. "The full chart doesn't fit on a computer screen," he says. "Each element is selected by a series of clicks, double clicks, or even triple clicks of the mouse." Furthermore, "Hunting, clicking and scrolling just to complete a simple physical exam is a tedious, time-wasting experience," he added.

In response, physicians have turned to three time-saving methods, each of which has the potential for abuse leading to the denial of payments that alarms Stack and the AMA.

The three methods – cut-and-paste, templates, and macros – can be logical and beneficial for static information, such as the date of an appendix removal, Stack says.

"Cut and paste becomes bad, and is appropriately criticized as cloning, when physicians reproduce information created by themselves or others, either without attribution or without attention to its accuracy," Stack says.

"It is not appropriate for a clinician to copy another professional's history verbatim and present it as if he had obtained it from the patient himself," Stack says. "It is often appropriate, however, for a clinician to document that she has reviewed the note of another professional, and to summarize the key elements in her own note, with attribution to its source."

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.

The AMA urges the Office of National Coordinator to address EHR usability concerns raised by physicians, and to take "prompt action to add usability criteria to the EHR certification process," Stack says.

He suggested ONC reconsider Stage 2 of Meaningful Use to allow more flexibility to providers to meet its requirements.

On Monday, the College of Healthcare Information Management Executives (CHIME) called for a one-year extension of Meaningful Use Stage 2. In a statement, CHIME said that the one-year extension would maximize the opportunity of program success.

The organization of healthcare CIOs said the additional 12-months for meeting Stage 2 would give

• Providers the opportunity to optimize their EHR technology and achieve the benefits of Stage 1 and Stage 2;
• Vendors the time needed to prepare, develop and deliver needed technology to correspond with Stage 3;
• Policymakers time to assess and evaluate programmatic trends needed to craft thoughtful Stage 3 rules

CHIME defended much of the federal incentive program's progress to date, arguing that fundamental shifts in health IT adoption and EHR product capabilities have been made possible through the policy of Meaningful Use.

CHIME's statement follows concerns levied by six Senators that the current direction of the HITECH program is flawed. A white paper released April 16, "REBOOT: Re-examining the Strategies Needed to Successfully Adopt Health IT," outlines several concerns including increased health care costs, lack of momentum toward interoperability, patient privacy, and long-term program sustainability.

The REBOOT report "highlights a number of fair and responsible criticisms of the program and it echoes many of the concerns CHIME has voiced over the last three years," CHIME's letter said. "But given the nation's increased adoption of EHRs, the increased investments in interoperable solutions and the early-stage transformations encountered every day by our members, we remain convinced that the trajectory set by Meaningful Use is the correct one.

"CHIME believes the industry's guiding principle should be to maximize the opportunity of program success and monitor the timelines needed to do that. For this reason, we formally and strongly recommend a one-year extension to Stage 2 before progressing to Stage 3 of Meaningful Use," the organization concluded.

In its letter, CHIME also called upon Congress to request an update from ONC on what technologies, architectures, and strategies exist to mitigate patient matching errors; seek feedback from the public via congressional hearing or other formal commenting mechanism; and determine how current work at the HHS Standards and Interoperability Framework could be leveraged to address the foundational challenge of patient data-matching.