An article in the Fierce EMR daily newsletter titled EHR Fraud: A Slippery Slope caught my attention, not because electronic health records have the potential to perpetuate fraud, but for the fact EHRs potentially promote abusive coding and billing Consider the templates and “ease of use” structured drop down menus, not to mention wide spread, epidemic cut and paste and carry forwards.  Witness the prevalence of inconsistencies in a History and Physicals and progress note content, one area of documentation states patient is not a smoker while another piece of documentation in the same document states patient is a 50 pack year smoker with continuous chronic smokers cough. The piece of documentation stating patient is never a smoker likely was entered as part of a point and click drop down menu.

Another common documentation concern is incongruence between the physician’s recorded History of Present Illness, Physical Exam and diagnosis of acute respiratory failure in the assessment within the History and Physical. The HPI may describe a patient with extreme shortness of breath for the last three hours, the constitutional part of the physical exam may state alert and oriented x 3 in no acute respiratory distress, the respiratory portion of the exam may state lungs clear to auscultation, yet the physician’s clinical impression includes acute respiratory failure. Once again, inconsistencies in documentation most likely are attributable to drop down point and click menus promoted by electronic health record vendors as a “real time saver.” The big question that remains is did the physician even perform an exam of the lungs, instead clicking on the box in the EHR.

Read the article here

The creation of templates and power chart notes promoted by EHR vendors as a means of saving time have the definite potential for reporting work not actually performed by the physician, potentially perpetuating the reporting and billing for physician work not actually performed, certainly representing abusive coding and billing practices. The OIG, concerned about potential upcoding and E & M level creep facilitated by the widespread implementation and use of the electronic health record, has conducted and released several reports on this very subject; Not all Recommended Fraud Safeguards Have Been Implemented in Hospital EHR Technology (, CMS and Its Contractors Have Adopted Few Program Integrity Practices to Address Vulnerabilities in EHRs, (, and Improper Payments for Evaluation and Management Services Cost Medicare Billions in 2010 (

The use of scribes as a means of improving and efficiency in clinical documentation is gaining widespread popularity and use. Scribes have been billed as a cost effective way of optimizing physician productivity and streamlining the medical record documentation process in both the office and hospital setting. The scribes are often times nurses, nurse practitioners, physician assistants or medical students who assist in the dictation or entry of patient information pertaining to the patient encounter. There are pros and cons to the use of scribes, the pros being enhanced physician productivity, enhanced physician satisfaction as well as patient satisfaction with the physician devoting more time to patient care and less time with data entry in the electronic health record. Cons include added costs to the physician practice for the scribes, the learning curve associated with a new process being introduced to the physician’s daily practice of medicine and the issue of the scribe performing documentation outside their scope of practice as well as concerns with the overall accuracy of the scribed reports. Another Fierce EMR article titled Do EMRs make it too easy to fudge documentation points out that the use of scribes may have the potential to contribute to documentation of care not actually provided, once again perpetuating the capabilities of EHR that include cut and paste, carry forwards, and use of macro templates that contain prepopulated information.  Read the article here

What Are the Possible Solutions?

Getting back to the basics of medicine is the real solution, referring to bell weather dictation that was the standard of documentation prior to the transition to the electronic health record to meet meaningful use requirements. Physician dictation of patient care is intuitive to the practice of medicine, allowing the physician the opportunity to record their clinical thoughts, clinical judgment, medical decision making and thought processes inherent to the practice of medicine. There is no interruption or interference with patient care, a large physician complaint associated with their use of the EHR. Mobile apps on I phones allow the physician to perform their dictation of patient care in real time as he/she is engaging with and examining the patient, relieving the physician of the inefficient dictation after the patient encounter, often times at the end of the workday when patient information is not as fresh in their minds. These apps offer many additional features such as ability to enter reminders or alerts for the physician or other ancillary care providers when the patient returns to the office for additional care or the next time the physician sees the patient on daily rounds in the hospital. A firm offering this mobile app to enhance and improve physician clinical documentation includes Command Health (

I encourage you to check out this mobile app offering and consider a demo, evaluating its capability and ability to effectively address the above outlined shortcomings and potential issue of abusive documentation, coding and billing practices including cut and paste, carry forwards and inconsistent clinical documentation from a reimbursement and legal liability standpoint