EHR templates have long been under scrutiny, but only now are consequences being established for the use and mis-use of templates. In a recently published addition to its instructions for payment review contractors, Centers for Medicare and Medicaid Services (CMS) states that templates do not provide adequate documentation of clinical encounters. In fact, in cases where templates are used without other documentation, progress notes will not qualify for Medicare payments. As stated in CMS instructions:
“Review contractors shall remember that progress notes created with Limited Space Templates in the absence of other acceptable medical record entries do NOT constitute sufficient documentation of a face-to-face visit and medical examination.”
This change in CMS review guidelines follows a string of criticism in recent months regarding the limitations, and even unlawfulness, of EHR templates. While not all templates use or allow for the much-maligned copy-and-paste feature, all templates limit user input in some way, whether it be by pick-lists, checkboxes, or boilerplate fields. Further, some templates are built primarily to maximize revenues, not to document detailed information about the care provided. CMS has come down particularly hard on these templates, stating:
“Physician/LCMPs should be aware that templates designed to gather selected information focused primarily for reimbursement purposes are often insufficient to demonstrate that all coverage and coding requirements are met.”
The risks and limitations presented by templates will be under heavy attack for a long time to come, and prospective EHR buyers must make themselves aware of these risks. If you are shopping for an EHR, make sure to ask template-based EHR vendors lots of tough questions. While all templates are templates in the end (and template-free alternatives, while few, are available), certain templates do put physicians at greater risk than others. As the financial and legal challenges to templates continue to mount, it is critical to implement an EHR system that allows you to capture patient care in your own words, and at a level of detail that properly documents each case.
All practitioners will agree that patients are more than simply lists of symptoms; it seems that CMS is finally beginning to punish EHR users who attempt to reduce patients to lists and checkboxes.
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When I interview, and exminae patients I cannot follow charts, dropdowns, etc. My questions, and findings lead to other questions and searches. My findings often do not fit into neat little diagrams or algorithims. The only way I can enter them into my notes is via my own scribbles.I must enter my findings at the time of the exam. Afterwards I might forget something. Also typing or dictating or filling out blanks divorces me from the patient, making him or her feel like an object rather than part of the process. It is also simply rude.If losing a percent or two to penalties then so be it. I will not sacrifice a good exam for the sake of filling out a questionaire.Also, as implied in Dr. Barakeh’s comments. Third party payment is the biggest culpret in the dumbing down of medical care. The patients no longer have very much say in their health care. This needs to be strongly addressed. He who pays the piper calls the tune.
Your blog is really awesome. I really enjoy it. The risks and limitations presented by templates will be under heavy attack for a long time to come, and prospective EHR buyers must make themselves aware of these risks.
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