We are fast approaching an impasse regarding the deployment of EHRs in hospitals. Hospitals are spending millions, or sometimes billions, of dollars on systems that are hindering the efficiency of their most critical assets, nurses and physicians. Jacob Reider, the Acting National Coordinator for Health Information Technology, recently commented on the "usability" of EHRs: ...[A]s a physician who has used an EHR in my clinical life since 2001, I worry that some of the usability challenges that we early adopters tolerated “for now” (a decade ago) remain unresolved (see: Usability of EHRs remains a priority for ONC).
So how do physicians and nurses deal with the incessant demands of EHRs to enter mandatory information or perhaps unnecessary steps that in the past they could have avoided? As I discussed in a previous note, EHRs provide three techniques for documenting patient care in the most efficient manner: (1) document by exception (check one box); (2) enter templated data; and (3) bring forward data (i.e., cut-and-paste) (see: Three Ways to Document a Physician/Patient Visit in an EMR).
There is a general distrust of box-checking, templated reports are increasingly viewed with suspicion (see: Distrust of "Templated" Physician Notes in EHRs; Implications for the Future), and now a report by the OIG singles out the cut-and-paste option (i.e., cloning) as potentially fraudulent (see: Report Finds More Flaws in Digitizing Patient Files). Below is an excerpt from the relevant article:
Although the federal government is spending more than $22 billion to encourage hospitals and doctors to adopt electronic health records, it has failed to put safeguards in place to prevent the technology from being used for inflating costs and overbilling, according to a new report by a federal oversight agency. The report, released...by the Office of the Inspector General for the Health and Human Services Department, is the second in two months to warn about flaws in the oversight of the ambitious federal program aimed at converting patient records from paper to electronic....The report was especially critical of the lack of guidelines around the widely used copy-and-paste function, also known as cloning, available in many of the largest electronic health record systems. The technique, which allows information to be quickly copied from one document to another, can reduce the time a doctor spends inputting patient data. But it can also be used to indicate more extensive — and expensive — patient exams or treatment than actually occurred. The result, some critics say, is that hospitals and doctors are overcharging Medicare for the care they are providing.
Here's an excerpt from a previous note about the EHR data entry paradox (see: EMRs and the Data Entry Paradox; Same Concept Not Applicable in the LIS World):
The EMR data entry paradox relates to the fact that the physicians entering clinical data are often pressed for time and do not perceive that they derive any major benefits from this documentation. Because of this, the quality of some of the data may be suspect. Moreover, physicians are accustomed to telling a narrative story in the medical record and often balk at entering structured data which is easier to analyze but may hinder the development of such a narrative. Finally..., physicians and nurses may be under pressure from hospital executives to use EMR documentation to maximize reimbursement.
Here's another quote from my note referenced above (see: Three Ways to Document a Physician/Patient Visit in an EMR):
So when exactly does an automated EMR feature designed to save time and energy when documenting physician care lead to a scam? The answer to this question seems obvious to me. A scam occurs when documentation in an EMR is generated automatically and with little or no forethought by the physician about the status of the patient. What is going through a physician's mind in such a setting is obviously hard to document. However, it often becomes evident ex post facto. For example, a note may indicate that a patient is doing well but lab or imaging studies performed at approximately the same time provide evidence to the contrary.
To recap, physicians and nurses are being forced into new behaviors that did not exist before EHRs and that are now viewed with suspicion by the OIG. Some of these new behaviors are actually being encouraged by hospital executives to maximize revenue, analogous to the "facility fee" upcharges used by some hospitals (see: Do facility fees pay for better care or upcharge patients?).
I personally do not have a clue about where the solution lies to this EHR dilemma. I don't believe that Epic and other EHR vendors will extensively modify their EHR products to better accommodate to the workflow needs of physicians and nurses and increase EHR usability. Perhaps, in time, we will breed a generation of physicians who will become more accustomed to the inefficient design of the EHRs.