Disputing that physicians are purposely using electronic health records to generate higher Medicare billings and “gaming the system,” the American Medical Association says federal policies themselves put providers in a Catch-22 situation. One fix, according to the AMA, is to reconsider Stage 2 meaningful use requirements.

During a May 3 “listening session” with federal officials, AMA Chairman Steven Stack, M.D., walked through the cumbersome documentation workflows of an EHR. He showed why it is necessary and appropriate for physicians to cut-and-paste information already in the EHR when documenting a new encounter. “Simply stated, many EHRs are not friendly to the user and rather than improving physician efficiency, they are a widespread source of frustration,” he said.

Stack took issue with Medicare carriers that have issued rules that they will deny payment if charts look too alike. “In this instance, even when clinicians are appropriately using the EHR, a tool with which they are frustrated and the use of which the federal government has mandated under threat of financial penalty, they are now being accused of inappropriate behavior, being economically penalized, and being instructed ‘de-facto’ to re-engineer non-value-added variation into their clinical notes. This is an appalling Catch-22 for physicians.”

Stack gave several examples of why documentation from different clinicians can make different patient charts look so similar. For instance, if a physician has a particularly good way of documenting a finding or condition, other physicians may adopt it. This is not fraud, but certainly is “cloning,” which federal officials have raised concerns about, he acknowledged. “Since we are not talking about a college thesis, the concept of plagiarism is moot but we are still left with lots of clinical charts that all look remarkably alike.”

He also explained why cutting and pasting static information in an EHR when documenting a new encounter is a logical and beneficial use of the technology. “If Mrs. Jones had her appendix removed in 1977 that date will not change for the rest of her life. Additionally, if she learned that she was allergic to penicillin in 1977 when she had that appendectomy, that information will also follow her for the rest of her life. So long as these items are accurate, it makes good sense to carry them forward throughout the electronic health record so every clinician has this information.”

The bottom line for the AMA is that it is not reasonable of federal officials to be critical of physicians struggling to comply with the inadequacies of mandated EHRs, “particularly when the physician community has vocally and repeatedly raised many of these concerns from the very start,” Stack said. He offered three ways to address the concerns of EHR usability:

* The Office of the National Coordinator for Health Information Technology should promptly add usability criteria to the EHR certification process,

* The Centers for Medicare and Medicaid Services should provide clear and direct guidance on the permissible use of EHR clinical documentation for purposes of coding and billing, and

* Stage 2 of meaningful use “should be reconsidered to allow more flexibility to providers to meet these requirements while the EHRs are better adapted to accommodate the diversity of clinical settings and appropriate variation in workflows.”

The AMA testimony is available here.

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