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Discuss clinical documentation in times of a pandemic/crisis. We have listed below some documentation requirements, as stated by our governing bodies like CMS. There are also strong recommendations of what needs to be included in an EHR record. But how does this change in the midst of a pandemic? During COVID-19, nursing has become overwhelmed by the sheer number of acutely ill patients.
1-How can facilities change the documentation requirements so that the charting doesn’t become more burdensome?
2- What do you feel are the most important pieces of a patient chart that have to remain? And what do you think can be omitted? Think hard about this. Because this is our reality today.
FACT SHEET
Electronic Health Records Provider
The cost of health care in the United States continues to rise, but the overall health of the nation is not necessarily
improving or keeping pace with other countries.[1] In 2009, the United States government began taking new steps
to transform our nation’s health care delivery system with the use of electronic health record (EHR) technology.
An EHR is a digital version of a patient’s paper chart and broader health history designed to be used both internally
and externally by multiple entities.[2, 3]
The 111th Congress passed the American Recovery and Reinvestment Act, and on February 17, 2009, President
Obama signed it into law.[4] One of the purposes of this Act is to furnish “funding to strengthen the health
information technology infrastructure” through the Health Information Technology for Economic and Clinical
Health (HITECH) provision.[5]
At the June 15, 2009, American Medical Association Conference in Chicago,[6] President Obama encouraged
health care providers to move from paper health records to EHRs. More recently, The Office of the National
Coordinator (ONC) for Health Information Technology (IT) released a 10-year vision paper for the state of health
IT by 2024. The goal is to achieve interoperability among the various health IT platforms, which in turn would
help reduce costs, allow patients more control over their information and decision making, and generally improve
patient health.[7] Why is it so important for providers to implement EHRs?
The Benefits of Electronic Health Records
Documentation is often the communication tool used by and between providers. Documenting a patient’s
record with all relevant and important facts, and having that information readily available, allows providers to
furnish correct and appropriate services that can improve quality, safety, and efficiency. EHRs can help improve
communication between providers through real-time access to valuable information. Surveyed medical providers
reported the following benefits of using EHRs:
• Real-time access to complete patient records at the point of care (real-time access can improve care delivery
and improve care transitions from one service or provider to another, which can lead to improved
population health over time[8]);
• Clinical alerts and reminders that reduce and prevent medical errors;
• Decision support, diagnostic aids, and elimination of duplicate tests;
• Reliable e-prescribing with fewer medication errors;
• Interface between e-prescribing systems and State Prescription Drug Monitoring Programs;
• Reduction in paperwork;
• Greater coordination of care;
• Legible records;
• Interface with labs;
• Patient portals that allow electronic interaction between the provider and patient;
• Electronic referrals; and
• Improved coding and billing.[9]
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A recent RAND Report, commissioned by the American Medical Association, found physicians agree with the
theory and use of EHRs, particularly when they perceive increased quality of care for their patients and anticipated
improvements in EHR interfaces and information exchange functions.[10]
Words of Caution
EHRs allow medical professionals a seamless approach for coordinating and managing their patient records.
They can help reduce paperwork, eliminate duplicate tests, and facilitate code assignment for billing. However, it
should be noted that recent reports indicate physicians are concerned about system interoperability, documentation
overload, and untested billing systems.[11]
While EHRs can improve health care delivery and provider services, they can pose provider challenges. Challenges
include, but are not limited to, privacy and security, author identification, altering entry dates, cloning, upcoding,
and coding modifiers. Further details on each challenge are explained in the following points:
1. Security and Privacy—EHRs can offer multiple improvements over paper documentation. They can also
pose security and privacy issues, such as allowing a malicious user to obtain patient information. Providers
should be aware of security features offered and utilize them when using EHRs. Security features include
secure networks, firewalls, encryption of data, and password protection that ensures only appropriate or
authorized entities can access certain information. Sites where EHRs are maintained should be locked with
facility access restricted. EHRs should be backed up to control the risk of data loss from natural disasters
or system failure. In addition, edits, audits, and system logs should be enabled to track all persons accessing
and editing EHR information.[12] When using EHRs with mobile equipment, such as laptops and thumb
drives, be sure to encrypt the information to prevent disclosure of personal health information.[13]
2. Author Identification—Different providers may add information to the same progress note. When this
occurs, each provider should be allowed to sign his or her entry, allowing verification of the amount of
work performed and which provider performed the work.[14]
3. Altering Entry Dates—Be sure the EHR system has the capability to identify changes to an original
entry, such as “addendums, corrections, deletions, and patient amendments.” When making changes, the
date, the time, the author making the change, and the reason for the change should be included. Some
systems automatically assign the date an entry was made. Others allow authorized users to change the
entry date to the date of the visit or service. Some systems allow providers to make undated amendments
without noting that an original entry was changed.[15] If there is no date and time on the original entry or
subsequent amendments, providers cannot determine the order of events, which can impact the quality of
patient care provided.
4. Cloning—This practice involves copying and pasting previously recorded information from a prior
note into a new note, and it is a problem in health care institutions that is not broadly addressed.[16, 17]
For example, features like auto-fill and auto-prompts can facilitate and improve provider documentation,
but they can also be misused. 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. Using electronic signatures or a personal
identification number may help deter some of the possible fraud, waste, and abuse that can occur with
increased use of EHRs.[18] In its 2013 work plan, 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.[19, 20]
5. Upcoding—Upcoding, sometimes known as “code creep,” occurs when a provider bills for a higher Current
Procedural Terminology (CPT) code than the service actually furnished, resulting in higher payment.[21]
Again, auto-fill and auto-prompts can facilitate and improve documentation, coding, and billing, but if
used inappropriately, these tools may suggest a higher billing code and payment than the actual services
furnished warrant, resulting in an improper payment.[22] Claims paid without the appropriate supporting
documentation are improper payments, and providers must return them.[23]
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6. Code Modifier—A modifier is an extension of an assigned code, such as a CPT code. Two reasons for
using procedure codes include communicating the professional medical services performed and billing
for the services provided. Modifiers are used in conjunction with codes to complete the picture of the
procedures and services provided.[24] More complex services may require additional modifiers. When
using modifiers, medical professionals should only use them to clarify the procedures and services
performed and never for the purpose of increasing reimbursement.[25]
7. Transition from Paper to EHR—EHR users may continue to use paper records. Paper records are more
permanent, and it is easy to discern if they have been altered in any way. Edits to an EHR may not always
be obvious, so providers should establish safeguards to protect against fraud, abuse, and human error.
Some of the safeguards for paper records can be applied to EHRs, like documenting who enters or edits
data in an EHR, and, when creating backups (and, if paper records are retained), cross-checking the EHR
with the paper record. Additionally, an EHR may lack the visual cues (for example, the colored letter tabs)
that help a provider or staff member know they are working in the correct record. These potential issues
require specific training in EHR data entry and management.[26]
Electronic Health Records Delivery System Reform
Using EHRs has the potential to transform our nation’s health care delivery system by: providing real-time,
authorized, secure access to patient-centered records; protecting patient privacy; improving coordination
of care; reducing costs; and going beyond standard clinical data to provide a broader view of a patient’s
care.[27] This broader view allows providers to document personal, social, and environmental factors affecting
the individual’s health. For more resources on EHRs, visit https://www.cms.gov/Medicare-MedicaidCoordination/Fraud-Prevention/Medicaid-Integrity-Education/electronic-health-records.html on the CMS
website, or https://healthit.ahrq.gov/health-it-tools-and-resources on the Agency for Healthcare Research and
Quality website.
Conclusion
This fact sheet focused on potential program integrity issues while helping providers recognize the value of
moving from paper medical record documentation to EHR documentation. The Centers for Medicare & Medicaid
Services (CMS) provides health care for millions of Americans and is the “single largest payer for health care in
the United States.”[28]
Federal and State laws require providers to maintain the records necessary to “fully disclose the extent of services,”
care, and supplies furnished to beneficiaries,[29, 30] as well as to support claims billed. EHRs facilitate medical
record keeping and can improve the quality, safety, and efficiency of health care services. The U.S. government
passed laws that assist eligible providers, through financial incentives, to switch from paper health records to
EHRs. Visit https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html
to learn more about the Medicaid and Medicare EHR Incentive Programs.
To see the electronic version of this fact sheet and the other products included in the “Documentation Matters”
Toolkit, visit the Medicaid Program Integrity Education page at http://www.cms.gov/Medicare-MedicaidCoordination/Fraud-Prevention/Medicaid-Integrity-Education/edmic-landing.html on the CMS website.
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References
1 White House. Office of the Press Secretary. (2009, June 15). Remarks by the President at the Annual Conference
of the American Medical Association. Retrieved October 13, 2015, from https://www.whitehouse.gov/the_press_
office/Remarks-by-the-President-to-the-Annual-Conference-of-the-American-Medical-Association/
2 U.S. Department of Health and Human Services. Office of the National Coordinator for Health Information
Technology. What Is an Electronic Health Record (EHR)? Retrieved October 14, 2015, from https://www.healthit.
gov/providers-professionals/faqs/what-electronic-health-record-ehr
3 Garrett, P., & Seidman, J. (2011, January 4). EMR vs. EHR–What Is the Difference? Office of the National
Coordinator for Health Information Technology. Health IT Buzz. Retrieved October 14, 2015, from https://www.
healthit.gov/buzz-blog/electronic-health-and-medical-records/emr-vs-ehr-difference/
4 U.S. Government Publishing Office. (2009, February 17). American Recovery and Reinvestment Act. Pub. L.
No. 111-5, 123 Stat. 115. Retrieved October 13, 2015, from http://www.gpo.gov/fdsys/pkg/PLAW-111publ5/pdf/
PLAW-111publ5.pdf
5 U.S. Government Publishing Office. (2009, February 17). American Recovery and Reinvestment Act. Pub. L.
No. 111-5, 123 Stat. 246. [42 U.S.C. 300jj-31]. Immediate Funding to Strengthen the Health Information
Technology Infrastructure. Retrieved October 13, 2015, from http://www.gpo.gov/fdsys/pkg/PLAW-111publ5/
pdf/PLAW-111publ5.pdf
6 White House. Office of the Press Secretary (2009, June 15). Remarks by the President to the Annual Conference
of the American Medical Association. Retrieved October 13, 2015, from https://www.whitehouse.gov/the_press_
office/Remarks-by-the-President-to-the-Annual-Conference-of-the-American-Medical-Association/
7 U.S. Department of Health and Human Services. Office of the National Coordinator for Health Information
Technology. (2014). Connecting Health and Care for the Nation: A 10-Year Vision to Achieve an Interoperable
Health IT Infrastructure. Retrieved October 13, 2015, from https://www.healthit.gov/sites/default/files/
ONC10yearInteroperabilityConceptPaper.pdf
8 U.S. Department of Health and Human Services. Office of the National Coordinator for Health Information
Technology. (2014, March 20). Benefits of EHRs. Improved Care Coordination. Retrieved October 13, 2015,
from http://www.healthit.gov/providers-professionals/improved-care-coordination
9 U.S. Department of Health and Human Services. Office of the Naitonal Coordinator of Health Information
Technology. (2015, July 30). Benefits of Electronic Health Records (EHRs). Retrieved October 13, 2015, from
https://www.healthit.gov/providers-professionals/benefits-electronic-health-records-ehrs
10 Friedberg, M., Chen, P., Van Busum, K., Aunon, F., Pham, C., Caloyeras, J., … Tutty, M. (2013). Factors
Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and
Health Policy. The RAND Corporation With Sponsorship by the American Medical Association. Retrieved
October 13, 2015, from http://www.rand.org/content/dam/rand/pubs/research_reports/RR400/RR439/RAND_
RR439.pdf
11 Friedberg, M., Chen, P., Van Busum, K., Aunon, F., Pham, C., Caloyeras, J., … Tutty, M. (2013). Factors
Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and
Health Policy. The RAND Corporation With Sponsorship by the American Medical Association. Retrieved
October 13, 2015, from http://www.rand.org/content/dam/rand/pubs/research_reports/RR400/RR439/RAND_
RR439.pdf
12 U.S. Department of Health and Human Services. Office of the National Coordinator for Health Information
Technology. (2015, April). Guide to Privacy and Security of Electronic Health Information, version 2.0.
(Chapter 6). Retrieved October 13, 2015, from https://www.healthit.gov/sites/default/files/pdf/privacy/privacyand-security-guide.pdf
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13 U.S. Department of Health and Human Services. Office of the National Coordinator for Health Information
Technology. (2014, March 21). Your Mobile Device and Health Information Privacy and Security. Retrieved
October 13, 2015, from https://www.healthit.gov/providers-professionals/your-mobile-device-and-healthinformation-privacy-and-security
14 American Health Information Management Association. (2013, August). Integrity of the Healthcare Record:
Best Practices for EHR Documentation. Retrieved October 15, 2015, from http://library.ahima.org/xpedio/groups/
public/documents/ahima/bok1_050286.hcsp?dDocName=bok1_050286
15 American Health Information Management Association. (2013, August). Integrity of the Healthcare Record:
Best Practices for EHR Documentation. Retrieved October 14, 2015, from http://library.ahima.org/xpedio/groups/
public/documents/ahima/bok1_050286.hcsp?dDocName=bok1_050286
16 U.S. Department of Health and Human Services. (2012, September 24). [Letter from Secretary Sebelius and
U.S. Attorney General Holder]. Retrieved October 15, 2015, from http://www.modernhealthcare.com/Assets/pdf/
CH82990924.PDF
17 U.S. Department of Health and Human Services. Office of Inspector General. (2013, December). Not All
Recommended Fraud Safeguards Have Been Implemented in Hospital EHR Technology (pp. 3 and 14). Retrieved
September 17, 2015, from https://oig.hhs.gov/oei/reports/oei-01-11-00570.pdf
18 American Health Information Management Association. (2009). Electronic Signature, Attestation, and
Authorship (Updated). Retrieved October 15, 2015, from http://library.ahima.org/xpedio/groups/public/
documents/ahima/bok1_045551.hcsp?dDocName=bok1_045551
19 U.S. Department of Health and Human Services. Office of Inspector General. Work Plan Fiscal Year 2013.
Retrieved October 14, 2015, from https://oig.hhs.gov/reports-and-publications/archives/workplan/2013/WorkPlan-2013.pdf
20 U.S. Department of Health and Human Services. Office of Inspector General. (2013, December). Not All
Recommended Fraud Safeguards Have Been Implemented in Hospital EHR Technology. (pp. 3 and 14). Retrieved
September 17, 2015, from https://oig.hhs.gov/oei/reports/oei-01-11-00570.pdf
21 U.S. Department of Health and Human Services. Office of Inspector General. (2010, March 4). Testimony of
Inspector General Daniel Levinson Before the House Appropriations Committee, Subcommittee on Labor, Health
and Human Services, Education, and Related Agencies (p. 2). Retrieved October 14, 2015, from https://oig.hhs.
gov/testimony/docs/2010/3-4-10LevinsonHAppropsSub.pdf
22 Payment Accuracy. Improper Payments Overview. Retrieved October 14, 2015, from https://paymentaccuracy.
gov/about-improper-payments
23 Improper Payments Elimination and Recovery Act of 2010. Pub. L. No. 111-204, 124 Stat. 2227 (f)(1&2).
Retrieved October 14, 2015, from https://www.whitehouse.gov/sites/default/files/omb/financial/_improper/
PL_111-204.pdf
24 2013 CPT Professional Edition. (Foreword, 1st paragraph, pg. v). Chicago, IL: American Medical Association.
25 Centers for Medicare & Medicaid Services. (2014, July). Avoiding Medicare Fraud & Abuse: A Roadmap for
Physicians (p. 5). Retrieved October 14, 2015, from https://www.cms.gov/Outreach-and-Education/MedicareLearning-Network-MLN/MLNProducts/Downloads/Avoiding_Medicare_FandA_Physicians_FactSheet_
905645.pdf
26 American Health Information Management Association. (2013, August). Integrity of the Healthcare Record:
Best Practices for EHR Documentation. Retrieved October 13, 2015, from http://library.ahima.org/xpedio/groups/
public/documents/ahima/bok1_050286.hcsp?dDocName=bok1_050286
27 Garrett, P., & Seidman, J. (2011, January 4). EMR vs. EHR—What Is the Difference? Office of the National
Coordinator of Health Information Technology. Health IT Buzz. Retrieved October 20, 2015, from https://www.
healthit.gov/buzz-blog/electronic-health-and-medical-records/emr-vs-ehr-difference/
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28 Centers for Medicare & Medicaid Services. (n.d.) CMS Roadmaps Overview. Retrieved October 14, 2015,
from https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGen
Info/Downloads/RoadmapOverview_OEA_1-16.pdf
29 Social Security Act § 1902(a)(27). Retrieved October 14, 2015, from https://www.ssa.gov/OP_Home/ssact/
title19/1902.htm
30 Centers for Medicare & Medicaid Services. The State Medicaid Manual. Services. Provider Approval/
Agreement Procedures, 4602 A (p. 4-604). Retrieved October 14, 2015, from https://www.cms.gov/Regulationsand-Guidance/Guidance/Manuals/Paper-Based-Manuals-Items/CMS021927.html
Disclaimer
This fact sheet was current at the time it was published or uploaded onto the web. Medicaid and Medicare policies
change frequently so links to the source documents have been provided within the document for your reference.
This fact sheet was prepared as a service to the public and is not intended to grant rights or impose obligations. This
fact sheet may contain references or links to statutes, regulations, or other policy materials. The information
provided is only intended to be a general summary. Use of this material is voluntary. Inclusion of a link does not
constitute CMS endorsement of the material. We encourage readers to review the specific statutes, regulations,
and other interpretive materials for a full and accurate statement of their contents.
December 2015
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