While an 18-month-old child can easily navigate today's smartphones and tablets, physicians with seven years of advanced clinical training “are brought to their knees” by an EHR, and even after months of use, physicians are unable to return to their pre-EHR levels of productivity, he said.
Simply stated, Stack said, “many EHRs are not friendly to the users,” and instead of improving productivity, they are “a widespread source of frustration.”
In September, HHS Secretary Kathleen Sebelius and U.S. Attorney General Eric Holder warned provider organizations that federal authorities would intensify efforts to determine whether providers were using healthcare information technology to improperly increase Medicare payments. Their warning followed the publication of research that indicated the level of evaluation and management codes rose over a time frame that coincided with the increased adoption of health IT.
The federal government has spent $13.7 billon to incentivize the adoption and use of EHRs by hospitals, physicians and other eligible professionals since 2011 under a program of the American Recovery and Reinvestment Act. More than three-fourths of hospitals and nearly half of eligible professionals have received EHR incentive payments thus far under the program.
E&M codes are used to reflect and provide higher compensation to physicians for the intensity of their work in treating a patient.
Since 1995, when the E&M coding system came into use, the widespread adoption of EHRs and progression toward team-based care, both good trends, “are rapidly changing physician documentation,” Stack said. That can be “pure torment” for physicians who must select each element on an EHR template “by clicks, double clicks or triple clicks.”
The most common way around these tedious processes with templates, he explained, are macros that fill in pre-determined fields for patients with similar conditions. Another is by cutting and pasting elements, such as historical patient information from a previous record, or the text of a “pithy” description of a condition written by that physician or even a peer, into a new record. These short cuts make a physician more efficient, but none of this constitutes fraud, according to Stack.
“If Mrs. Jones had an appendectomy in 1977, that information will remain unchanged for the rest of her life,” Stack said. There is no value added by a physician re-writing that fact. It becomes improper when they reproduce information without attribution to the source, if it's from a record created by another physician, or if there is inattention to accuracy and “glaring inaccuracies” are copied forward, he explained.
Before EHRs, according to Stack, the great bugaboo was the variation in medical records, but now, EHR templates, macros and cut and paste contribute to an “overwhelming homogeny” that is being viewed by some payers and the compliance community with suspicion.
Writing a note “is not a college thesis,” Stack said. “As long as the description matches the clinical need, this is not fraud, but it is cloning.”
Forcing physicians to “reengineer variation” into their records simply to pass compliance creates “an appalling Catch-22 for physicians,” he said.
The benefit to patients from EHRs “is undeniable, but we're not quite there yet. We still have some work to do.”
Stack asked ONC to add usability criteria to its testing and certifying program that vendors must pass to make their systems eligible for use in the EHR incentive payment program. He also called on the CMS to work with the physician community in developing an official guide for providers on coding and billing with an EHR, and then amend the Stage 2 meaningful-use criteria for the incentive program to “allow more flexibility” to meet these requirements.
Dr. Bruce Siegel, president and CEO of the National Association of Public Hospitals and Health Systems, also said no one should be surprised that providers will be capturing more information with electronic health records systems and as a result, “You are going to see increased coding.
“That should be expected,” Siegel said. “It's not a sign that something bad is happening.”
Follow Joseph Conn on Twitter: @MHJConn