Electronic Health Records – Internal Control Issues

The Health Care Compliance Association recently sponsored a webinar in NYC. The webinar highlighted the following features of electronic health records (“EHR”) that can be misused because of a lack of internal controls and training by the users:

• The “make me an author” tool: It allows physicians to substitute their signature for that of another person who entered notes in the EHR. Some vendors even allow the user to opt out of tracking changes, which makes it impossible to figure out who edited the records. Our experience with audits suggests that the inability to know when edits are entered will cause serious audit issues regarding proper documentation.
• EHRs with no place for providers to include narratives: If EHRs lack space for providers to write their observations about patients on a given visit, they are at greater risk of appearing identical to each other. When medical records appear identical from one visit to the next, auditors deny claims for the reason that medical necessity cannot be established. Medical necessity is currently the number one reason that payers are requesting refunds.
  
• Copy and paste or cloning: Documentation is considered cloned if every entry in the record is worded the exact same way or is very similar to previous entries. When entries are copied and pasted without being edited, this doesn’t meet medical-necessity requirements for Medicare coverage because documentation isn’t specific enough to the patient and his or her experience. This has been a major focus of Medicare Administrative Contractor audits the last two to three years.
• Failing to enter information in relevant fields: Medicare won’t pay for inpatient admissions without a physician order, but patients may be discharged without a flag in the EHR that it’s missing. Our coders still find missing information during our audit reviews.
• Templates: Most EHRs have built-in time savers, such as self-populating fields. They insert the patient’s medical history into the record when the physician checks a box. That multiplies the effect of even one incorrect piece of data. Templates can be useful as guides, but staff must be careful to insure the data entered is correct.

Many of our clients and contacts view an EHR as a “black box” that solves all of their coding and documentation problems. We continue to remind our clients and contacts that EHRs are just a tool and that effective training on their software is critical to efficiently and effectively utilizing the software.