The electronic health record (EHR) has solved the illegibility issue of handwritten notes, but the downside and unintended consequences have been of equal or greater importance. The cult of the EHR “copy and paste” (CP) club in hospital care makes defending a Medicare billing audit a daunting task should a physician be required to justify their level of professional billing codes. The much more important issue, however, is that patient care has suffered.
I spent 35 years in an internal medicine/geriatrics group practice before becoming a chief medical officer (CMO) as well as the physician advisor in charge of appeals for a large health care system. I have reviewed thousands of chart notes before and after the advent of the EHR. All denials for payment by health plan insurers were challenged by me and my staff of six nurses. My job was to justify that a patient required hospitalization and that the hospital and doctor deserved to be paid. Good documentation was imperative for a successful challenge of nonpayment. Often, the format of copy and paste (CP) left much to be desired.
There is nothing inherently wrong with CP, and if used correctly, it can be efficient. That said, the current state of CP is very limited in revealing substantive clinical information regarding a patient’s hospitalization. The story of the patient’s hospital course is often lost.
CP progress notes tend to look nearly identical from one day to the next. It is not uncommon for the subjective portion of a progress note to remain unchanged for days—or in one case, two weeks. The plan of care notes also remain the same, even when the clinical condition of the patient has changed dramatically. Worse yet is when a CP note is copied from the wrong patient or from the same patient’s prior admission—though this is rare.
This CP issue is a common problem throughout the U.S. and not unique to my hospital system. I have spoken with medical directors across the country in my role, and they uniformly lament the lack of good documentation needed to follow the hospital course when daily “mirror image” notes are used. The EHR and CP as currently utilized add little clinical value from one day to the next, aside from updating labs, imaging, and medications, which are generated automatically. All these impressive lab and imaging results are meaningless without interpretation and a plan for addressing any changes.
Beyond the risk of payment denial, the greater concern is the potential and actual adverse consequences in care. A covering physician or a consultant who joins the case later often struggles to determine what has happened to the patient prior to their involvement. This issue becomes especially dangerous when a patient decompensates and an emergency evaluation by a critical care or emergency department physician is required. In such cases, immediate action is necessary, and without clear documentation, unnecessary harm may occur. A chronological account of the clinical course is imperative for effective patient management, particularly in a crisis.
Another unintended consequence of the EHR/CP is the lack of communication among treating physicians. The EHR has inadvertently exacerbated the problem of fragmented care, leading to duplicate testing, conflicting orders, increased risk of adverse drug interactions, patient harm, and prolonged hospitalizations—just to name a few.
Before the EHR, if I could not read a handwritten note from a consultant, I would call them for their thoughts on the case. Likewise, when I was writing my notes, other doctors would call me with similar questions. At a minimum, a chart note from a fellow physician should contain pertinent clinical information that assists in patient management. CP notes may look polished, but they provide limited information about what is actually happening with the patient. The EHR and CP have contributed to a culture of “get the note done and get out.” Perhaps one reason physicians do not read each other’s notes is that CP notes often contain little meaningful clinical information. Test results and imaging data are worthless without interpretation relevant to the patient’s care.
An example of this issue involves a case in which a nephrologist and a cardiologist were treating the same patient—one wanted to restrict fluids, while the other considered the patient “dry.” Their notes and orders conflicted, but neither doctor was reading the other’s documentation. It was as though they were treating two different patients. As a result, busy nurses have been required to call physicians more frequently for order clarifications since the advent of the EHR. Another reason for decreased physician communication may be the time wasted scrolling past the “noise” in the EHR to find a meaningful clinical comment.
One particular case highlights the consequences of this lack of communication. A patient with diabetes mellitus was admitted with chest pain while on hemodialysis. The admitting nephrologist appropriately requested a cardiology consultation. The nephrologist’s plan of care noted that he would await the cardiologist’s recommendations for further management. The cardiologist saw the patient later that afternoon—the same day of admission—determined that the pain was atypical, and signed off on the case. However, the nephrologist’s notes for the next seven days continued to state, “will await opinion of cardiology for further workup.” The patient remained hospitalized for six extra days receiving only hemodialysis, which could have been provided as an outpatient. The health plan denied payment for six days of unnecessary hospitalization, but more importantly, an immunosuppressed patient was exposed to unnecessary risks, including hospital-acquired infections and medication errors.
The EHR alone is not solely responsible for the shift in how hospital care is delivered. Today, physicians focus more on completing a chart note rather than ensuring the quality of the information entered. What happened yesterday is important, but what is going to happen today matters even more. CP is an easy way to populate data into a chart, but its value is lost if the content lacks critical thinking about the data entered.
In a Medicare or health plan professional billing audit (evaluation/management), auditors expect to see clinical reasoning regarding the myriad diagnostic results populated by the EHR. Identifying an elevated creatinine level is insufficient; what matters is why the creatinine is elevated and what therapeutic options exist. Simply put, this is good clinical care. Meeting audit criteria for professional billing codes is important, but documenting sound hospital care is essential. Data is important, but without clinician expertise, it is meaningless.
The EHR may have been created with good intentions, but in its current use, it has not improved patient care. In fact, it may have diminished the quality of hospital care. The EHR and CP have bloated medical records with “lots of sizzle and no steak.” Collegial communication remains the foundation of good clinical care.
Ben Hourani is an internal medicine physician.
