South Florida Hospital News
Sunday September 20, 2020

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June 2017 - Volume 13 - Issue 12


Technology Trap: When EMR Software Does So Much lt Begins to Resemble Fraud

Electronic Medical Records (EMR) software functions have very practical benefits and are increasingly required for reimbursement purposes. The purpose of technology is to create efficiency and software aids a physician by ensuring a note is complete for treatment purposes and contains all the information required to make a claim valid and payable. However, a side effect of the efficiency of such software is that it can generate records so similar from visit to visit and patient to patient that the records can appear fabricated.

A typed clean looking note looks more professional and avoids errors in interpretation; however, in some ways a handwritten progress note, even in potentially indecipherable physician handwriting, can carry an authenticity lacking in a computer generated record. In a recent case, a client physician was being questioned about his records and the investigator focused a particular day and questioned why, record after record, for patients large and small, different genders and ages, all had nearly the same words and phrases in the progress notes. The obvious answer, that the EMR software was designed to aid in the generation of the notes, led to the question of whether the physician could prove in any way that he was even there that day.

While the accusation was in many ways silly, the premise is one that can be problematic, In fact, regulatory authorities have cautioned providers about several EMR software related fraud issues. One such issue is what auditors call "cloning." This is the practice of copying portions of notes from one patient visit for use in another. There is nothing wrong with carrying information forward from the initial or prior office visit that can illuminate the rationale for treatment on a given visit and, for billing purposes, justify the use of one code over another by reinforcing the complexity of the interaction. However, this becomes a problem when the copied information is virtually all that appears in a note. CMS, in addressing this issue, has indicated "The medical record must contain documentation showing the differences and the needs of the patient for each visit or encounter. Simply changing the date on the EHR without reflecting what occurred during the actual visit is not acceptable." Beginning in 2013, the U.S. Department of Health and Human Services, Office of Inspector General (HHS-OIG) indicated that due to the growing problem of cloning, its staff would be paying close attention to EHR cloning. In 2016, a cardiologist group in New Jersey settled false claims allegations with CMS for $422,000 which included an allegation of cloning of patient encounter notes,
Another issue involves templates, ENIR software uses templates to create the form and structure of a medical record. With respect to SOAP notes, templates can fill in portions of a note using terms that are commonly used in diagnosis and treatment. In practices that are specialized or treat specific types of medical conditions; the notes, spread across not only the patient file but all of the practice records, begin to look very familiar, and at times, suspicious, The Medicare Program Integrity Manual specifically addresses templates, and cautions physicians, "Some templates provide limited options and/or space for the collection of information such as by using "check boxes," predefined answers, limited space to enter information, etc. CMS discourages the use of such templates."
The recording of patient notes and charting is one of the less enjoyable parts of practicing. Particularly in hospitals, harried physicians fall behind. In Florida, at a recent Board of Medicine meeting, a physician was disciplined after being reported to the Board by his own employer, a hospital, for chronic ·failure to keep up with records. Software, with the efficiencies created by copy and paste and fill in templates, makes life much easier in that regard but physicians should be cognizant of when the software is too efficient and the notes start to look very repetitive. Charted patient encounters should have some originality to make sure the world can tell the physician was actually there that day.

Bernard M. Cassidy, Partner, Lubell Rosen, LLC, can be reached at (954) 880-9500 or

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