Coding & Reimbursement

EMR No Cure for Garbage In, Garbage Out

By Suzanne L. Corcoran, COE

Electronic medical records (EMR) are being widely adopted. The federal government is encouraging this adoption with bonuses paid to practices that successfully implement EMR. However, for all the benefits EMR offers practices, don’t be lulled into a false sense of security: Coding errors are still possible.

Here are some concerns you need to keep in mind.

Q What are some advantages of EMR?

A There are many, including improved access to the records. For those of you who haven’t heard: No more lost charts! For offices with multiple locations, no more dragging boxes of charts between offices. Another cause for rejoicing: Legibility is no longer an issue.

Q How do we avoid problems associated with cloned records?

A As auditors, our preference would be simply to disable the copy-forward function. Some practices do this, but doctors and staff are understandably unhappy having to re-enter repeated information. The physician also wants ready access to the prior visit’s notes as a reference.

Some EMR systems allow information to be carried forward as a temporary entry that must be validated to become part of the permanent record. The technician or physician must “touch” each element and confirm it is correct and pertinent based on the current examination. Some do this by changing the color of the entry. Others use an overlay screen. With this method, the physician can see the prior entry but still must record today’s exam elements.

In this way, the credibility of the record is strengthened and some criticism mitigated.

Q What other issues should we consider with EMR?

A There are too many to discuss in detail in one column, but here are some examples:

• Nonsense entries, especially in the chief complaint and HPI.

• Unreliable entries in the examination.

• Data always looks real, even if it is not.

• Charting by default can hide medical problems.

• Quantity of data can create information overload.

• Physician signatures and attestation requirements.

• Timeliness of entries.

• Updating or correcting the medical record.

Q What pitfalls should we be aware of?

A The Office of Inspector General believes EMR may contribute to over coding, primarily due to the ease with which more complete entries can be made compared with paper records. CMS, local Medicare and Medicaid contractors, and other third-party payers recognize that one of the favorite features of EMR is the ability to “copy forward” or “clone” elements of the medical record.

However, be warned that cloning history or exam elements puts the validity of the entire record at risk. Repeated identical entries cause the reader to wonder whether the exam even occurred or if the information is real. We’ve seen cases where repeat entries, including typographical errors, were identical over many visits.

Q What do you mean by nonsense entries?

A Many EMR systems use drop-downs or pick lists of key words to quickly enter patients’ complaints. The system then builds a sentence or phrase around the key word. This can lead to results that leave you scratching your head in puzzlement. Here are some real examples from charts we have reviewed:

• “Decreased vision in both ears.”

• “Patient complains, no complaints.”

• “Diabetes in both eyes 4 years.”

• “Borderline diabetes, it affects vision, not affected.”

• “IOL eval in both eyes for one year.”

Obviously, computers do not always gather our logical responses. You must have a system in place to review entries and correct them.

Q Are there any other issues we need to consider?

A We discussed the rules for physician signatures in a previous column, and will address updating and correcting medical records as well as other issues in future columns. Overall, keep in mind that computer output is only as good as the input. The old “GIGO” rule still applies: garbage in, garbage out.

Computerizing medical records makes them more accessible and more legible, but does not protect us against human error. Review the records and verify the entries before closing the record. OM

Suzanne L. Corcoran is vice president of Corcoran Consulting Group. She can be reached at (800) 399-6565 or www.corcoranccg.com.