re: EHRs Under Fire For Inflating Medicare Bills
"The core of the allegations is that EHRs enable doctors to copy and paste findings from previous notes into current notes, providing documentation that can be used to justify higher codes. "
Really ... ???
I don't doubt that there are "allegations" about copy and paste, but is this different in substance from using "coded comments" in computerized reports for radiology, pathology, clinical history, etc.? Is this different in substance from entering "WNL" for an organ system examination (e.g., Neurological Exam) on a History and Physical?
The legal argument to be proven is analogous to proving that WNL actually means "We Never Looked." Whether a doctor presses a key (say, "F7") and the EHR generates a lucid, readily understood description of some clinical observation/interpretation or if the doctor copies that same text from a previous clinical record of the same (or another patient with the same condition) should be immaterial.
Standardized text that is continuously reviewed in clinical usage is more likely to be correct, complete and consistently interpreted -- it doesn't mean that the clinical evaluation is missing. It can be an indicator of refined clinical processes ... although it does carry an associated risk of mental short-cutting and not fully thinking through what is going on. Standardized text is a good tool for improving communication, but it needs continuous monitoring of its usage.