Do EMRs make it too easy to fudge documentation?

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Scribes in the healthcare industry are becoming increasingly popular. They allow physicians to focus on treating patients while freeing docs from the data-input required to document each visit.

But one scribe, writing anonymously at KevinMD.com, says electronic medical records systems make it too easy to bill for things the physician did not do--such as counsel a patient to stop smoking.

Physicians can make "macros" which autopopulate certain parts of the chart, documenting all the parts of a physical exam, for instance, whether or not those actions were completed.

In other cases, physicians have suggested the scribe wasn't paying attention when those tasks were done, according to the article.

There are about 10,000 scribes working in hospitals and medical practices in the U.S., the New York Times reported recently. Their job is to pay attention and to document accurately.

Too many EMR features are tied to billing and not patient care, Ira Nash, a cardiologist and senior vice president and executive director at North Shore-LIJ Medical Group, wrote previously at KevinMD.com.

A U.S. Department of Health & Human Services Office of Inspector General report recently criticized the Centers for Medicare & Medicaid Services and its contractors for doing too little to address vulnerabilities in electronic health recordsCopy-pasting and overdocumentation, the report's authors said, are two easy ways for fraud to occur in EHRs; sometimes, it's the fault of pre-population by EHRs and sometimes, it's a lack of oversight from doctors and nurses who enter information via copy-paste and don't review or correct it.

To learn more:
- read the KevinMD.com post

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