Today's Practice: Changing the Business of Medicine | Page 13

A Balancing Act

Alok Prasad

specialists are forced to address patients in words
that are not their own and may or may not apply
directly to the situation at hand. Templates need to
provide efficiency without straitjacketing the medical professional into a script that sounds completely
unnatural and ill-suited for the task at hand. As
such, EMR template customization should enable
medical professionals to alter templates as much or
as little as needed based on the patient's unique
situation.
While some of these customizable features may help
practices encourage more expedited documentation
from physicians, they also need to be careful that
they aren’t erroneously causing inaccurate information within their patient records. This not only
could result in incomplete patient data, but also
signal an audit if they are participating in any financial incentive reimbursement programs.

Beware of Chart Notes Cloning
Medical groups need to specifically be careful about
“whole-note cloning,” the practice of copying and
pasting previous notes into the EMR in an effort to
speed documentation. While this documentation
technique can increase efficiency, it also can threaten the trustworthiness of records. Indeed, copying
and pasting allows physicians to easily incorporate
lab tests, round the clock vitals, and every conceivable report in a single progress note. However, the
practice can result in inaccurate documentation as
well. In fact, EMR cloning has resulted in Medicare
and other insurance companies denying payments,
thus inviting case review and new legal liabilities.
Recent studies have also established EMR cloning
as a potential factor in poor patient outcomes, such
as when the cloning of glucose labs in hospitalized
diabetics becomes harmful. As such, medical practices need to make sure that they are always documenting care so that it relays the particulars of the
patient’s illness, with events sequenced chronologi-

cally, along with appropriately inserted clinical
commentary and discussion of treatments.4
Common documentation risks that can result
from cloning include:
Vital signs that never change from visit to visit;
Information “copied and pasted” from a different
patient’s record;
Documentation from another provider including
their attestation statement;
And, identical verbiage used repeatedly for all
patients seen by a provider for a specific timeframe
with little or no modification regardless of the nature
of the presenting problem or intensity of the service; at
times, such verbiage includes contradictory indications (i.e., use of pronoun “he” instead of “she,” indication that patient has no pain when the documentation includes a record of pain) 5

Use Modern Techniques to Streamline
Documentation
Speech recognition is a feature that can help to
streamline documentation efforts. With advancements in technology, it is possible for physicians to
achieve 9