Outlawing Templated Notes in the Electronic Health Record

It was just a matter of time until this would happen.

Buried in the middle of this New York Times article on The Ups and Downs of Electronic Medical Records is the observation that a Medicare administrative contractor dubbed National Government Services has announced that it, on behalf of CMS, will “deny payment” for medical services that are documented in an electronic health record (EHR) using “cloned documentation.”

The topic was covered more than 2 years ago. “Cloned documentation” is the widespread practice of copying, pasting past documentation in an EHR into the current encounter record to inflate the recorded patient evaluation to primarily justify a higher payment. Thanks to this OIG report, the Feds have figured out that the true value proposition for an EHR is not “meaningful use” but wasteful abuse.

In addition to congratulating the Times for their crack cutting-edge reporting, here is a prediction…

1. The mere threat of payment denials and the possibility of sanctions will prompt health administrators everywhere to announce at medical staff meetings that “cloned” notes are verboten.

2. Until the “templated note” functionality is deleted in future EHR software updates, physicians will respond to this latest edict from their administrators in the traditional manner: they’ll ignore it.

3. Once the cloned note option is no longer available in the course of a patient encounter and physicians actually have to manually type out much of their encounter notes, patients will wonder why their docs are spending even MORE time staring at the computer screens and less time talking to them.

4. As clinic work flows get even more gummed up and waiting lists expand, outfits like National Government Services will announce that it will deny payment for documented medical services that are not provided in a timely manner.

Silly you say? Think again.

Jaan Sidorov, MD, is a primary care internist and former Medical Director at Geisinger Health Plan with over 20 years experience in primary care, disease management and population-based care coordination. He shares his knowledge and insights at Disease Management Care Blog, where this post first appeared.

12 replies »

  1. Remember how EMR’s were sold to us as “you see fewer patients, but with cut and paste you can meet the requirements for higher codes for the patients yo do see?”

    Bait, meet switch.

  2. There is a distinction to be made between copy/paste a previous providers note into your own VS templated documentation
    and It does not seem to be being made.

  3. Don’t blame the HIT community. The $20 whore here was the medical professional societies.

  4. I have been on emr for over ten years, the selling points were the ability to increase coding, easy documentation via template, would be mandated at some point by payors and gov’t.

    Fast forward 10 years, all those aspects of the emr are now being used against use. Thank you HIT community

  5. The systems were certified by the feds…i am happy to just dictate. They wanted the data to be interoperable and transferable. It is a big pain in the butt for us real docs.

  6. I have performed and then written, dictated or templated the same ‘normal’ comprehensive physical examination since I have been in practice. The vitals, gender specific differences and basic physical descriptors are of course unique, however the use of templated PhEx has saved me time and provided reproducible accuracy.

    If I were to de-evolve back to written notes, the content would be no different, what is the difference then other than more and less accurate work?

  7. Dictation (with or without NLP) is still a great solution if you have no need for consistent sets of structured data based on best practices and have no need to improve physicians efficiency and capacity. Meaningful use is just the tip of the iceberg as far as requiring real data. Just wait, the need for more data at the same time as the fees for services system wanes, a lot of obsolete approaches are going to implode.

  8. I think this problem is one created by physicians, in collaboration with maybe somewhat inconsiderate introduction of EMR.

    I think that “note bloat” and improper use of template is a real problem for complex patients. As long as we do not have good alternatives that have been a good track record for the specialty/patient population at hand, physicians should just go back and dictate notes. EMR does not mean that physicians must use templates or history checklists (not Gawandes checklists, in case someone wonders) – our entire institution (which is os meaningful in its EMR use) uses mostly dictated notes in outpatient care, and copying and pasting appears limited and reasonable. In other words, you can document just fine with an EMR if you want to.

  9. Outlawing templated notes in the EHR either means more doctors as distracted data trolls seeing fewer patients with more work, or it is time to go to Medical Care Coordinators™ who remotely do the data entry/management and free up doctors to be doctors who can see more patients with less total work. This is far more productive and less intrusive than pen paper and collects the data needed to improve care.
    But… old habits and obsolete EHR systems/processes die hard.

  10. The Dichotomy is very well put. Damned if you do, damned if you don’t.

    One of the biggest impediments to adoption of EMR has been reduction in productivity versus paper and pen.

    But, just like everything else, it is so easy to blame the tools and technology for all the malaise affecting healthcare. If the intent is to ‘overcode’, then nothing can stop the providers from doing so. You remove ‘templates’, there will be something else that they will figure out.

    Un-Templating is obviously not the solution.