All right, we are going to talk about one of my favorite topics to talk about. We'll talk about the electronic medical record, and it's literally the good, the bad, the ugly. We've seen great documentation with the EMR. We've seen bad documentation with the EMR, and we've seen just downright ugly documentation with the EMR. So one thing that I always comment on is templates. We got all these different electronic medical records out there. There's all sorts of ways to document a visit, whether you're dictating, transcribing, using a template, whatever, free text, just typing it in yourself, whatever it is, there's some downsides to having everything loaded and at your fingertips, and you can literally click a button, and all of this explosive amount of data comes out, and then I'm doing an audit, and I'm looking at the note, and it doesn't even make sense, or there's contradictions, or whatever the case may be. So we're going to go through safe and effective use of templates, talk about cloning and what happens if you clone, and I mentioned this earlier, and then dictation with voice recognition software, and then CMS electronic record fact sheet that I want to show you that they've actually addressed this issue as well. So I have a question. If a note contains contradictory information, who is responsible for correcting that information? A, the coder or biller, B, the medical assistant, C, the patient, or D, the provider who performed the service? 98% says the provider who performed the service, so yes, that's correct. Ultimately, the provider is responsible for that documentation, whoever's name is on the claim is responsible, and I know we have our staff, and most practices are set up in a way that you have medical assistants and nursing staff, whatever, that input information into that medical record, and that's great. It's wonderful because it saves the provider a lot of time, but you still have to keep in the back of your mind that you're the provider, you're the one that's on the claim, so you're responsible should things be incorrect and not accurate. So we've stated medical necessity probably 50 times today, but that, yes, that should be the driving factor for templates. Every note should not look identical and must be specific to the patient's chief complaint. So I look at the flow of the note when I do a review. I look at the HPI, I make sure that the HPI is contained within the HPI, and then the HPI is elaborated on as far as how long, associated symptoms, any other issues surrounding that chief complaint. And then I take that, and that should flow then into the assessment and plan of care as well to make sure that, again, you're addressing everything, you want to get credit for everything as well. So sometimes I will look at a note, and there will be three or four things addressed in the HPI, but only one thing mentioned in the assessment and plan. But then you've got the opposite of that sometimes, where you address one thing and there's 14 diagnosis codes listed or diagnoses listed in your assessment. So just be aware that all of that should flow and match. Providers should carefully review telehealth physical exam templates. So back when the public health emergency happened, majority of practices, we were all doing basically the majority telehealth. And post-telehealth or post-pandemic or whatever, there's payers that are requesting records for all those telehealth services that we build. And so we've done also telehealth reviews for practices. And we saw one of the big area of concerns was the template. It's like, so you see the patient virtually, but you're using an in-person template. So then there's sometimes where it's like, well, you can't do that just by seeing the patient. So making sure that your physical exam is pertinent. So if you're doing an audio video with a patient, general statements in the physical exam should be documented. So something that you can see, but not something that you can touch. Audio only, that's another one. That should never include an exam. And trust me, we have seen several audio-only encounters, and there's physical exam components. But again, it's a matter of creating a template for AV, creating a template for audio only. And then, of course, your inpatient, your inpatient, or your, sorry, in-person encounters. Address cloned documentation with your providers. Use the basic soap note format for follow-up notes in the office and hospital, and keep it pertinent to the current encounter for follow-up care. One of the bigger areas that we see the cloning is hospital follow-up visits. So it's not necessarily an extreme concern in GI. I think more of the hospitalist, or when you round daily, daily, daily, daily for a week to two weeks or whatever, you really have to watch for those cloned records. We know that most EHR, hospital EHRs give you the ability to pre-populate a note from one day to the next, or copy-paste, copy-paste, copy-paste, but it's all about customization. Providers have a medical legal responsibility to ensure the note they sign is complete and accurate. Okay, so again, you've got your medical staff entering information, just making sure that that information is correct. So here's some examples that we're talking about. The HPI states the patient has been experiencing epigastric pain on and off for the past three months. The system denies abdominal pain. Here's another one. Chief complaint states six-month follow-up of GERD, but HPI says the patient is here for new change in bowel patterns. So in that instance, the chief complaint doesn't even go with the HPI. And most of the time when I see this issue, it's because, let's say it's a patient, and it's typically your follow-up patients. Let's say the patient calls, says, I need to make an appointment. I've got this diarrhea that I'm having going on. Okay. Well, last time you saw him was for GERD, right? And so if whoever schedules that patient doesn't update that and that information pulls over into that note, that chief complaint is not going to be accurate. So again, take a quick look at your note before you sign it and make sure that that chief complaint is correct and accurate. We also see HPI contradicting the assessment and plan. So the assessment should include conditions that are addressed during that encounter and any risk factors that impact your decision-making. We never ever recommend using a problem list. A problem list is more of a list of all the things the patient's ever had in their medical record. Okay. So whatever you treated them for five years ago is not pertinent to today's visit and should not be in your assessment today. The other thing is this is what I addressed today. So again, we talked about clone documentation, redundancies, and this should be a practice policy. There should be restrictions on the amount and the ability to copy and paste. There definitely needs to be some more free texting involved. Providers must recognize that every patient encounter should be unique, must ensure the health service provided is documented distinctly from others. And we are now trained on the quality, not the quantity of that medical record. And they will request consecutive visits and disallow the visits that are not customized and are not, you know, updated. I always say, so, you know, we know Dragon is one of those more popular voice recognition systems out there. And I always say, be sure to train your Dragon to ensure documentation makes sense. We have seen so many patient encounters during reviews and we'll look in the HPI and like the HPI talks about the patient's issues that they're here for. And then it picks up a conversation outside the hallway talking about an iPhone and what, how was your lunch? And that gets pulled into the HPI of your note. I've seen it and I've seen a lot of it. So making sure that you take a quick look over that stuff, make sure it's correct and make sure it's accurate. Blanks are the same way. So if you've still are doing the transcription and you get your, whether it's a visit, like a consultation or an operative report, if you get that sent back and there's blanks all over it, don't just leave the blanks blank. That means they couldn't understand what you said or it didn't come through right or something. There was a glitch. So being sure to fill in that information. And remember what you sign is a medical legal document and your name's on the claim. Okay. So this is from CMS and it's their electronic medical record fact sheet. And so I'm going to kind of just go through this with you and make some comments. So they say EHRs allow medical professionals a seamless approach for coordinating and managing their patients' records. They can help reduce paperwork, eliminate duplicate tests, and facilitate code assignment for billing. However, it should be noted that recent reports indicate physicians are concerned about system inoperability, documentation overload, and untested billing systems. While EHRs can improve healthcare delivery and provider services, they can pose a provider challenge. Challenges include privacy and security, author identification, altering entry dates, cloning, upcoding, coding modifiers. So further details on each challenge are explained. So they say security and privacy issues. Be aware of security features offered and use them while accessing the electronic medical record. Only authorized entities should be able to access the EHR. Providers should be secured networks, firewalls, encryption of data, and password protection. The EHR should have a security feature to track all persons accessing and or editing the EHR information. All right, so what this means is you should have some security in place. We can't all just log into your medical record. I should not be able to log in and fix Dr. Littenberg's upper endoscopy that he did because I noticed he left off the biopsy. I shouldn't be able to do that. So there should be features there. Update your passwords. Log off before you leave. There's one thing that last year I was visiting my grandpa in the hospital and he actually was a very, very small hospital and they were still sharing rooms, which floors me. There was a divider, but still there were two people in the room and the nurse went to the other patient, took his vitals and all that stuff, and then walked over to my grandpa and said, oh, I'll be right back. I got to go get something X, Y, Z, and just left that computer open with that other patient's information just there. So you have to definitely make sure that your staff members, hospital staff members know the importance of logging off, leaving, making sure that the security is there. After identification, different providers may add information to the same progress note. When this occurs, each provider should be allowed to sign his or her entry, allowing verification of the amount of work performed and which provider performed the work. So again, I kind of talked about that with those shared visits. When your nurse practitioner, PA, starts the note, make them finalize it, sign it, then you come in as the physician and add an attestation. I should be able to see who did what part of that note. Another issue, altering entry dates, your EHR system must have the capability to capture changes to the original entry in the form of an addendum, correction, or deletion. When making changes in the record, the date, time, and author, making the changes as well as the reason for the change should be documented. And we went over this, Kathy and I both did, for signature requirements. This is Medicare's policy. This is their fact sheet on it. So they're looking for this stuff, and there is a way. Some providers are like, oh, well, they can't tell that I unlocked my note and added this and did this and did that. Oh, yeah, they can. You leave breadcrumbs, everything you open, everything that you edit, all of it. So just make sure you're doing it correctly. And then, of course, they address the cloning. And for them, they say cloning involves copying and pasting previously recorded information from a prior note to a new note. The medical record must contain documentation showing differences and the needs for the patient for each visit or encounter. Simply changing the date without reflecting what happened during the current visit is not allowed. The HHS and OIG indicated that due to the growing issue of cloning, its staff would be paying close attention to clone charts. Upcoding. Auto prompts and pre-filled templates can help the provider improve documentation. However, if used inappropriately, can lead to higher billing and payment. Providers have a medical legal obligation to document and code the service provided. You know, with this one, I don't think that's much of a, it's not as big of a concern. Now that we really don't, we're not bean counting things. So there were a lot of coding software programs that would just up code based on history and exam. So you had a comprehensive history, comprehensive exam. Oh, it's a level five. You know, there was nothing that was filtering decision-making to that aspect. Well, now that those two don't factor, the history and exam don't factor into our level, you know, we're seeing, we're seeing a little bit better approach on this one. So if you have an EHR in your, in your practice and you're using the coding calculator or whatever it's called, make sure you're filling in those blanks correctly. Because still at the end of the day, you're the one that's responsible for the level, not your, your software, not your EHR and not AI. Built-in coding software, again, can suggest an incorrect CPT code if the provider is unaware of how to use the program. So more information on this, you can find this in the integrity education manual. It's a provider fact sheet, good, helpful information there. All right. And that is it.

electronic medical records

documentation practices

telehealth challenges

cloned documentation

patient information security