Electronic Health Record Software: A Boon For Efficiency Or Gateway To Fraudulent Shortcuts?

By John H. McCord, DPM

   I like gadgets. My Blackberry is linked to my GPS so I can talk to the map while I am driving my fuel sipping Prius. Seminars have always been a challenge to me because all the new medical gadgets are on display and for sale in the exhibit halls. I have learned to leave my credit cards with high limits locked in the hotel room safe.

   I attended a seminar about seven years ago and saw the ultimate gadget in electronic health record (EHR) software. This was the answer to my dream. The doctor carries a tablet computer into the exam room and clicks little boxes with a little plastic tool while the patient is trying to explain the foot problem.

   At the end of the visit, one has completed the documentation, written prescriptions, made follow-up plans, calculated diagnostic and treatment codes, and generated and submitted a bill. I was ready to buy the thing but my credit card was locked in the safe.

   On the elevator ride to my room, I knew I needed to know more about EHS before I spent the cost of a new Prius and totally changed the culture of my practice. I left the credit card in the safe and returned to the exhibit hall. The salesman was all smiles until I told him about my sudden case of cold feet.

   EHR or EMR or whatever it is called is said to be the wave of the future in medical documentation and billing. The insurance companies like it and large practices like it. It has some obvious advantages. Documentation is uniform. Billing is expedited. Paper charts are eliminated.

   I have been receiving EHR generated chart notes over the years with physician referrals or when I request a past medical record from another doctor. Unfortunately, these records tend to be a bizarre collection of minutiae that make no sense and are nearly impossible to interpret. Most go on for four or five pages. All of the negative findings are charted. Templates go into great detail to describe the examination and findings. Yet I can rarely find the patient’s chief complaint, the doctor’s actual diagnosis or the reason for the referral.

   My most intimate experience with EHR was a few years ago when a 3,500-pound SUV rear-ended my Volkswagen Beetle. The cops insisted I go to the hospital because I seemed dazed and walked funny. My wife tried to explain that I usually seemed dazed but I went to the emergency room.

   They took X-rays and after about two hours a young doctor poked his head into the exam room. He told me the X-rays were OK and I could leave. The doctor darted away and I asked the nurse if that was it for my examination. She said I could leave.

   I reviewed my bill, which showed a charge for a full level 3 physical exam by the doctor. The unfortunate young fellow did not realize I was on the hospital board and medical executive committee. I talked with his boss and reviewed my “full work-up” that was generated by EHR with wordy descriptive templates. The examination that was documented would have taken 45 minutes.

   I recommended his dismissal. His boss told me he hated to lose the young doctor, who was his most productive ER provider. I had no doubt about his ability to generate revenue but fraud is fraud.

   I have had many other patient care experiences in which EHR software has been used creatively. One patient arrived in my clinic in a wheelchair. His recent record from the previous doctor was generated using EHR templates. An entry marked “gait analysis” indicated that he walked without an appreciable limp.

   I asked the patient how long he had been using the wheelchair. He told me he broke his back 30 years ago and has been paraplegic since. This did not adversely affect the patient’s care but made everything else in his record suspicious.

   Gadgets like EHR or EMR are useful tools in medical care but must be used in an honest manner. These gadgets should not simply be tools to chalk up more “bullets” to up the treatment code.

   There is an axiom in medical care that for every diagnosis missed by not knowing, ten are missed by not looking. I read that in a book written about veterinary medicine by Robert Sharp, DVM. It certainly applies to all forms of medical care and we should keep this in mind when we generate our documentation with a gadget.

Dr. McCord is a Fellow of the American College of Foot and Ankle Surgeons. He practices at the Centralia Medical Center in Centralia, Wash.

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