Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Wednesday, February 04, 2009

EMR Ethics

I find myself on the horns of an ethical dilemma. (Not the ethics of a horny dilemma; get your mind out of the gutter!) The proliferation of electronic medical records (EMRs) has generated a situation that really roasts my beef, and I am seeing it with increasing frequency. It's the flip side of the lawyers' old canard,
If it isn't documented, it didn't happen.
It seems that more and more doctors are taking that to mean that if something IS documented, then whether or not it actually happened is moot, at least as far as payment is concerned.

There are at least two specialist offices who regularly send me letters documenting examinations that I know for a fact did not occur. In one case, the proof is that they document procedures requiring a level of patient cooperation and vocalization incompatible with the patient's age. (ie, How do you get a two-year-old to tell you in which ear the tuning fork sounds louder?) In another, a full body exam is documented at each visit when only the affected limb was examined. Those are the only two where my level of certainty is 100%. There are many others that are highly questionable, but harder to prove because of patient unfamiliarity with examination procedures.

What's the big deal?

What most patients don't understand is that physicians get paid on the basis of what they write down. Of course, the documentation is supposed to accurately reflect what was done, but when the auditor comes along, all that matters is the paper trail. So if a doctor spends a great deal of time with a patient performing a complex evaluation but only writes a few words, he's at risk of not being paid; whereas if he writes pages of stuff that never happened, no one bats an eye. Most of the time, no one will ever know.

Just me.

Here's the dilemma: what, if anything, can I do about this? More to the point, what should I do?

I've spoken to the first office in the past. They claimed they had done all the procedures documented, and then offered to come over to my office to help me implement an EMR myself, given that they had just spent $250,000 on their new one and really liked the way it enhanced their income. The other office only started doing this more recently, and frankly the combination of anger and frustration has resulted in paralysis; I haven't talked to them about it either.

Besides, what would I say?:

Me: You're documenting fraudulently.
Them: So what? You can't prove it.

What else can I do? Is it worth trying to blow the whistle on these guys? I'm certain they'd easily survive any insurance audit, because the only way to prove them wrong is to call each patient and say, "Did the doctor do a complete physical exam each time you went for your broken foot?" Who's going to remember? More importantly, who's going to bother?

So all I can do is sit here fuming while these specialists laugh all the way to the bank. And the Obama administration wants to increase the prevalence of EMRs. Does anyone wonder why health care in this country is so expensive?


At Wed Feb 04, 10:05:00 AM, Anonymous Anonymous said...

I'm not sure how much EMR is at fault though. (I'm not EMR fan.)

At heart, the fraudulent doctor is at fault. Yes, the EMR made it easier but if the doctor was honest, it wouldn't matter. An honest physician wouldn't do that, no matter how easy it was.

If not EMR, a dishonest doctor is going to find some other way to defraud the system and his patients. The fault lies with the dishonest blackheart who sees his patients as dollar signs.

At Wed Feb 04, 01:14:00 PM, Blogger Margaret Polaneczky, MD (aka TBTAM) said...

Whistle blowers make a percentage of what the government gets in return, so there's an incentive for you...

But that doesn't really answer your question, does it?

I've had the same concern with EMRs over the years, and we struggle with these issues in our practice - how to make the EMR easy to use and as fast as the old paper when it comes to documenting vs having things default in that we may forget to delete later. The tempataion is to create default templates that drop normal exam elements in - problem with this is that you have to go back and delete the exam elements that you did not do. Sounds easy enough till you get distracted in the middle of charting by a phone call or your secretary, move on to another chart and forget to go back and change the exam elements.

Some of this could be honest mitakes/learning curve stuff on the part of these docs. Are they billing for the full exam or just the extremity? If it's the latter, it may be that their EMR needs tweaking to stop defaulting so much text in and they need to learn how to delete the defaults in their template.

Converting to an EMR is one of the most difficult things docs will ahve to do, and the price they may end up paying if the government starts to really look at errors may be much higher than that inital $250K.

I'd hang back for now if I were you and let things play out. UNless you know for sure they are doing it on purpose to defraud, in which case I say go for it - you've got several college tuitions to pay, after all...

At Wed Feb 04, 02:41:00 PM, Anonymous Anonymous said...

We use electronic records at the vet surgery's very few UK practices have paper now.

In UK the pet insurance industry is a huge business however it is a help not a hindrance having EMR. The insurance is not based on how much the vet has written but on the findings and treatment. If that took 3 lines it is treated the same way as if the vet had written 3 pages.

Given the state of the Vets handwriting l think this is all to the good. A lot more info can be placed onto the record, reminders generated and printed for vaccinations and parasite checks etc.

It is also harder to change records as paper can be thrown out and replaced, electronic records can not be edited once they are set that is it. Any opps l made a mess up l should have said .... has to be printed as a new entry.

From what you have described it is a badly run/designed system that has dishonesty built into the system. Surely insurance should be results based and justified not waffle and BS based.
If you find something then you had to examine xyz to get there.

At Wed Feb 04, 04:20:00 PM, Anonymous Anonymous said...

I'm going to go with pockets. The problem isn't the system, it's the lying sacks of diarrhetic goat effluvia entering the documentation.

At Wed Feb 04, 04:54:00 PM, Blogger OHN said...

This seems to be the same as billing a simple visit from an established patient, as a complex office visit. Our co-pay is the same either way but the physician reimbursement is larger. This is done routinely in our area.

I have often thought this was dishonest but then again his reimbursement is still minimal in relation to what is billed.

At Wed Feb 04, 05:08:00 PM, Anonymous Anonymous said...

I'm glad a doctor admits to this being a problem!!
I have pretty decent insurance and rarely ever pay anything on top of my co-pay. However, having been without insurance in the past it was absolutely vital for me to look at the bills I got from doctors. A few times I called and pointed out that I did not have a physical, but merely a check-up for bronchitis, and the likes. They changed the bill every time.

When I got back on insurance I started looking at EOB's because I started medical school and was interested in them. I was baffled!!! When I didn't have insurance it was fairly rare that I got overcharged, but now it's almost standard!!

My insurance got billed for me to see an MD at the ED, when I, in fact, saw an NP. They changed it and the visit cost over 200 dollars less, all of a sudden.
I saw an orthopedist and my insurance was billed for a "new problem", when it really was just a check-up. Again, much cheaper.

Are these billing "mishaps" truly mishaps, or are they simply the standard - charge more most times, get caught a few times, make more money in the long run?!
I'm pretty sure it's illegal to charge for services that were not rendered.

At Thu Feb 05, 01:30:00 AM, Blogger Unknown said...

Medicare & other third party payors take anonymous information on fraudulent billing. They won't necessarily make a change on one anonymous complaint, but with enough, that provider is flagged & if enough complaints come in, then the provider is audited. They get caught when they find exactly what you are seeing - procedures inappropriate for age, too many full physicals when the the provider schedule wouldn't allow enough time, etc.. Finally, the auditor interviews the patient.

It happens more often than you know! To report Medicare abuse, you call the office of the Inspector General - 1-800-HHS-TIPS.

The fine is tremendous - $10K per incident I think. This isn't Obama's fault & I like EMRs. Its unethical providers who are using EMRs.

Now, the question is - knowing what you know about the ethics of these specialists, will you still refer to them, even if you choose to do nothing at all?

At Thu Feb 05, 06:23:00 AM, Blogger #1 Dinosaur said...

Linda: I don't refer to either of the specialists mentioned. That doesn't mean my patients don't wind up there anyway. You'd be amazed at how little control I have over what other docs patients see.

At Thu Feb 05, 09:55:00 AM, Anonymous Anonymous said...

Perhaps an even more insidious result of EHR's is the standardized negative review of systems that are dropped into the record and then become "set in stone" even though many of the questions probably weren't asked. Eventually, if a patient becomes sick, all those negative ROS' may negatively influence the differential diagnosis of the physician who now has to treat the patient.

At Thu Feb 05, 10:11:00 AM, Blogger Unknown said...

That's why I dislike templates and EMRs.
There's a time crunch to get the documentation done and the natural instinct is to rattle off a "normal" exam or a "normal" ROS on a patient who appears "normal."
I think it's amusing when infants are deemed as being "A+Ox3" or their ROS states that they do not complain of headaches or vision changes.
The intent probably isn't there to defraud. It's probably just a case of clicking the "normal" box on an EMR when the "normal" moniker isn't a one size fits all designation.

At Thu Feb 05, 03:40:00 PM, Anonymous Anonymous said...

I'd go with Linda's suggestion; complaining to the offices in question isn't about to do much - they're not about to change for anything less than Mom or Dad catching them with their hands in the cookie jar.

But filing a complaint with the hotline every time you catch them listing a procedure that's obviously fraudulent? That is something doable - and, in time, it will make a difference; enough complaints, after all, and they'll start an investigation to see if there's anything to the complaints - and, at the least, they'll find those age-inappropriate procedures and those full-body exams that don't make sense for the time-frame or part of the body that was afflicted, not to mention the ones that just don't quite sit right with you.

Whether or not to let these offices know that you're going to complain is up to you - but I wouldn't, personally; they ought to know that what they're doing is wrong, and the problems they'll face if an audit turns up that they've got multiple instances of fraud on the books are on their shoulders...and wouldn't have been a risk if they hadn't been committing that fraud to begin with.

At Sat Feb 07, 02:11:00 AM, Anonymous Anonymous said...

But getting rid of EMR's is absolutely NOT the solution to dealing with insurance fraud. Our healthcare system is already wasteful and inefficient enough without our help in making it more so.

At Mon Feb 09, 04:57:00 PM, Anonymous Anonymous said...

Interesting article that I read shortly after reading this post. They fit together well!

At Thu Feb 12, 12:15:00 PM, Blogger ERMurse said...

I posted on this over a year ago. Yes you can do the same fraudulent documentation on paper by checking a series of boxes for a review of systems or using dictation templates but with most EMR's a single click of normal populates a full set of findings across all body systems. Its called an exploding note. The root cause is the financial incentive to document a review of symptoms and lack of standards on design of EMR charting. The exploding note is the selling point of a lot of EMR vendors. There is also a feature called copy forward where you can copy an entire not forward to the current date and time and edit any changes. Problem is its usually only the date of exam that gets changed. Vendors promise you will be able to increase your revenue and decrease the amount of time charting. It plays well with susceptible providers who think no one looks at the note anyway. There needs to be some very public examples made of practioners who produce fradulant documentation to shake up the industry.

At Sat Feb 14, 09:14:00 PM, Anonymous Anonymous said...

I know of a case in a Seattle ER in which the EMR for an ER visit for an adult female who fainted during a flight was merged with a 61 year old man who was treated for pneumonia.

She works in health care implementing ERM's and is a former firefighter and was very aware of what tests were ordered and performed. Upon discharge she noticed that the after visit summary discussed procedures that never happened (respiratory therapy) as well as drugs (class II narcotics) that she wasn't given. They had crossed out the errors but sent the digital copy to her primary doc.

Despite 3 months attempting to get the records corrected (she was also charged with the drugs and procedures the man was given) she was finally able to only get a note added that the H&P was not hers. Her insurance had already paid and she was unable to get anyone to believe that no blood work was done, that she wasn't given brochiodilators, that she wasn't discharged with meds or that she wasn't given the exams in the chart.

She filed a report with JCAHO online and they did an investigation but her chart remains incorrect.


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