While EHRs have been introduced with a view to improve medical documentation and thereby enhance the quality of patient care, this new system does raise certain compliance issues. Let us look at these new concerns.
- The â€śself-populatingâ€ť fields in most EHRs are intended as time savers, whereby providers can insert the patientâ€™s entire past medical history into each record by the simple click of a mouse, i.e. by selecting a check box. Now what is the issue involved? Some EHRs carry forward an entire patient assessment along with the patientâ€™s past medical history. This may create problems if providers are not wary enough to tailor each visit note to the visit performed. Documentation should be provided only for the services actually rendered on the particular visit. Take the case of an E/M service where the EHR brings forth an entire review of systems. Questions may arise in scenarios where the review of systems does not change from one visit note to another, or where the review of systems seems to be unrelated to the patientâ€™s chief complaint, or where it mistakenly includes info irrelevant to the patientâ€™s gender. It is possible that the integrity of the review of systems may be questioned in such instances.
- Sometimes EHRs bring forth also a narrative portion of the record where the physician includes information that is specific to his observations about a patient on a particular visit. This may pave the way for documentation that is internally inconsistent. It is important that all information that is automatically entered is carefully reviewed by the provider so that consistency is maintained throughout. Moreover, all medical records must contain accurate info regarding the patientâ€™s condition and services provided. Providers must also watch out for EHRs that automatically populate information prospectively and retrospectively, which is indeed a very risky prospect. Just think about diagnostic results being included in notes after the test as well as before the test! This will only lead to total denial of payment for all services, and worse still, throw aspersions on the integrity of the provider.
- Electronic health record templates may not be perfectly customized to a providerâ€™s specialty. Issues include the template containing information that may be irrelevant to the particular provider. Some other templates may not include a place for the provider to enter his observations regarding a patient on a particular visit. This shortcoming will make all medical records at all visits look identical and lead to claim denials.
Steering through Compliance Issues
Providers must be actively involved in choosing and implementing an EHR system. They must see to it that it is customized to their particular specialty so that compliance issues do not arise. The system should have adequate security mechanisms and providers must be knowledgeable about these. Most importantly, they must be fully aware of the capabilities of the software and understand the various fields that are likely to self-populate. All medical records should be reviewed for accuracy.