Clinical Documentation News Roundup: EHR and EMR Edition

Clinical Documentation News Roundup: EHR/EMR Edition

Clinical Documentation News Roundup: EHR/EMR Edition

It was a busy week for doctors, health care professionals and others interested in EHR and EMR policy. According to EHRIntelligence, "Christmas has come early" for those wanting to reassign certain incentive payments. Many organizations will need to check their policies as the federal government looks into copy-and-paste capabilities of some EHRs in an effort to fight billing fraud. Stories about fraud concerns popped up in other news outlets as well.

This week's Clinical Documentation News Roundup brings you the most important EHR and EMR news of the week.

  • CMS allows EPs to assign EHR incentives to Method II CAHs from EHRIntelligence: “Christmas has come early for eligible professionals (EPs) wanting to reassign their EHR incentive payments to Method II critical access hospitals (CAHs) care of the Centers for Medicare & Medicaid Services (CMS). The federal agency has issued a final rule for the Medicare and Medicaid Programs which impacts this subject of providers demonstrating meaningful use as part of the EHR Incentive Programs. Having upgraded its systems for identifying the National Provider Identifiers (NPIs) of these EPs, CMS is now in a position to process ‘take into account the services furnished by EPs in Method II CAH outpatient settings when we annually determined the hospital-based status of each EP for each payment year for purposes of the EHR Incentive Program.’ The upgrade impacts claims submitted no earlier than the beginning of Oct. 1, 2012, the start of Fiscal Year 2013. CMS has decided on a two-step process for handling payment year 2013 only.”
  • Fraud-Wary Feds to Regulate EHR Copy-and-Paste Function from Medscape: “The Centers for Medicare & Medicaid Services (CMS) is going to regulate the controversial copy-and-paste capability of electronic health record (EHR) systems in its campaign against billing fraud. CMS made its intentions known in response to a report released online today by the Office of Inspector General (OIG) of the Department of Health and Human Services (HHS). In a survey of 864 hospitals, OIG found that only one fourth had policies governing the use of EHR copy-and-paste functions. And only 44% had EHR audit logs that record the method of data entry, whether it is copy-and-paste, voice recognition, or keyboarding. OIG said that the ability to ‘clone’ chart notes from a previous patient encounter to help document the next one can help physicians work more efficiently, but also invite fraud, especially if no one edits the cloned information to make sure it's accurate and up to date. Government officials are worried that many physicians bill for higher levels of evaluation and management (E/M) services than warranted by cloning dense blocks of old patient information. For example, a physician may bring forward a diagnosis from an earlier visit — an infection, for example — that no longer applies.”
  • A Twist in the Newly Proposed Stage 2 and Stage 3 EHR Incentive Timelines from MedCity News: I was driving through the mountains last Friday at sunset when my phone started ringing. Now I don’t like to talk on phone when I’m driving, especially at dusk in the mountains, so I didn’t answer. The calls kept coming and by the time I pulled over 15 minutes later I had 9 voice mails. Every message was from a different person and essentially said the same thing: ‘Stage 2 Meaningful Use has been delayed.’  I could almost hear the champagne corks popping. It was like an early holiday present. All the fear and dread of what has been called the “perfect storm of 2014” (ICD-10, Stage 2, 2014 Edition EHRs, Affordable Care Act) suddenly starting looking a whole lot better. Funny how facts turn into rumors and spread like a wildfire.  Many of the headlines and Tweets coming from reputable sources proved to be wrong. Too bad we have to sometimes face the facts. Here they are, just the facts, and nothing more.”
  • OIG Report: Hospitals Need Better EHR Audit, Access Guidance from Health IT Security: “A recent Office of the Inspector General (OIG) report titled “Not All Recommended Fraud Safeguards Have Been Implemented in Hospital EHR Technology” gave some insight into EHR technology audit and access control capabilities and how healthcare providers are taking advantage of these functions. The annual cost of healthcare fraud is between $75 billion and $250 billion, according to 2009 CMS estimates, and OIG administered an online questionnaire to 864 hospitals between October 2012 and January 2013 to learn about the Certified EHR Technology hospitals are using. OIG found that nearly all hospitals with EHR technology had contractor RTI International (RTI)-recommended audit functions in place, but they may not be maximizing their potential. And hospitals were found to use a variety of RTI-recommended user authorization and access controls, with most using RTI-recommended data transfer safeguards.”
  • Providers Not Required to Keep EHR Audit Systems Turned On from Modern Healthcare: “If healthcare providers are using their electronic health records to falsify medical billing or cover their tracks after mistakes, there's an easy way for investigators to find out: Check the audit trail. Unfortunately, federal rules don't require healthcare providers to keep their automated audit systems turned on. A study out this week from HHS' watchdog office (PDF) finds that many healthcare providers can simply disable their logs or alter them after the fact—and experts say the problem may be far worse than what the study found. HHS' inspector general's office this week reported the results of a voluntary survey of all 900 hospitals that had received federal subsidies to buy electronic health record systems as of March 2012. The survey, which had a 95% response rate, found that 44% of the hospitals reported having the ability to delete their EHR audit logs. Another 33% could disable the audit logs, while 11% could edit the records at will.”

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