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Curbside Consult with Dr. Jayne 10/17/11

October 17, 2011 Dr. Jayne 3 Comments

Dear Dr. Jayne,

What’s your take on the following Medicare position?

When documentation is worded exactly like or similar to previous entries, the documentation is referred to as cloned documentation. Documentation exactly the same from patient to patient is considered cloned and often occurs when services have a specific set of limited or select criteria. Cloned documentation lacks the patient specific information necessary to support services rendered to each individual patient.

After doing cough/cold/flu clinics where patient after patient presents with similar symptoms, similar exam findings, while the HPI documentation may be different, there are only so many ways to document “nasal turbinates red, erythematous, swollen, lungs clear” and the advice to the patient nearly always remains “Rest, fluids, Tylenol, ibuprofen, return if condition worsens.”

Additionally, much documentation remains unchanged at a routine 3-6 month visit for diabetes, HTN, hyperlipidemia where a physical exam is performed thoroughly. Medicare requires the documentation for payment, but is now placing providers in a catch-22 where the documentation cannot be even similar. How different can one make an exam if little changes?

Must we now ditch those time-saving macros that document routine education in the chart, such as “Counseled patient regarding risks and benefits of medication, including the possibility of sedation and advice to avoid driving or operating power tools while on narcotics?”

Clone Trooper

Dearest Trooper,

My secret fear is that Medicare is building its own Clone Army of Recovery Audit Contractors to continue to torment and confuse physicians. If they’re now going to go after so-called cloned documentation, they’re going to have to go back to every History and Physical and every Discharge Summary that every resident has done since the invention of the Dictaphone.

I remember being trapped in Medical Records (before it became Health Information Management) with a stack of my cruel attending’s charts, dictating notes on patients I barely remember seeing. Unless they had a significant finding, everyone was “regular rate and rhythm no murmur, rub, or gallop; lungs were clear to auscultation bilaterally.”

I absolutely agree with you – there are only so many ways to say, “Patient is not a smoker.” Let’s see. PATIENT is not a smoker. Patient is NOT a smoker. Patient is not a SMOKER. Let’s try this: STOP smoking pot. Stop SMOKING pot. Stop smoking POT.

If I use the same simple sentence on every patient, does that make me guilty of cloning? Will the stem cell activists come after me too?

Frankly, I think Medicare shares responsibility for creating this kind of documentation. This isn’t a new problem with use of EHRs. It has been prevalent every since transcription services started charging by the line. Physicians learned to say the same thing in fewer and fewer words. This ultimately evolved into dictation macros and the concept has continued as voice recognition slowly takes the place of transcribed dictation. EHRs just jumped on a train that was already rolling at a good clip.

Medicare’s cousin, Medicaid, has also driven us to this. Has anyone ever seen an EPSDT form? This is a required form for pediatric well visits. It is required that providers fill out the same form (specific to age) for each patient. You are required to document mandatory anticipatory guidance by placing an X in a box. Thus, the forms look pretty darn identical when they’re done. Should I start doing cursive X on some forms and print on others? Should I alternate right and left facing check-marks? Why is Medicaid’s form OK but my own form causes cloning?

I do a lot of sports physicals, sometimes at a sports physical clinic. There is a mandated state form. Almost all of the teens I see are healthy. So what constitutes “patient specific information?” Maybe I should start finishing them up with “This blonde surfer dude in an Abercrombie t-shirt is cleared for contact sports,” or include “Patient has braces with alternating pink and green elastics” on the oral exam. Would this meet the CMS standard for unique documentation?

Then, what about the patients who have the same visit month after month? I have patients whose office visits are straight out of the movie Groundhog Day. Except for the vital signs, the visit never changes. The patient continues to be non-compliant. The murmur is identical from visit to visit (which is a good thing!) The assessment and plan are the same. I keep prescribing the same medications that the patient continues to not take correctly.

Let’s not even talk about group visits, which they want us to do as part of Patient Centered Medical Home initiatives. Of course your counseling is going to be identical for every patient – you only said it once because they were sitting there in a group, for goodness sake. If you try to change it up for the sake of making less uniform documentation, isn’t that fraud?

I think if Medicare wants to avoid cloned documentation, they should start paying physicians to document using well-crafted prose – or at least an incentive payment for complete sentences with reasonably correct grammar. For the ability to collect a higher fee, I’d even consider writing notes in the form of the Shakespearean sonnet. But with dropping reimbursements and rising costs, CMS is going to be lucky if they get a Haiku out of me.

Have a penchant for an Ode, some Tanka, the Jintishi, or maybe the anapestic tetrameter of Dr. Seuss? E-mail me.


E-mail Dr. Jayne.

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Currently there are "3 comments" on this Article:

  1. ‘Colonialism’ had it’s good and bad sides I am sure all will agree, depending on which side of the ‘standard’ you found yourself. So too for what I will term ‘clon-ialism’! Yes, you read that right! ‘Clon-ialism’!
    Read my observations/ramblings in ‘Monday Morning Update’ where I yearn for the age sadly gone by of lengthy, detailed, interesting and compassion fostering histories drawn out of the sick patient by truly caring physicians. The EMR does us NO justice in this realm, and given the time pressures MD’s are under nowadays we by necessity are urged to take short cuts. And so, ‘clones’ are born. We did this in the paper realm too….pre-printed diagnosis specific or complaint specific paper documents/orders.
    Think about it. ‘Clon-ialism’ comes in many forms, some favored, others not. The most favored example would be our pursuit of ‘standardization’. This is a form of ‘clon-ialism’ the Federal government, and our individual institutions would most certainly welcome us adopting. After all, we want our providers to provide the same care, to the same patients every time, and in so doing we attempt to replicate/clone ‘the standard’ (whatever that may be).
    So, ‘clone documentation’ good or bad? They have already decided!

  2. As with so many things “government” the intent is admirable but the actual outcome is oh so problematic. In the back of my mind I’m convinced that a bureaucrat in an office cubby somewhere came up with the idea that EMRs should be Meaningfully Used, and look where that got us. I can appreciate the concerns about blindly copy/pasting from one report to another. We’re in the business of trying to streamline documentation but not to the detriment of quality. Please pardon the musings of an everyday Joe, but, perhaps the answer lies in other areas of the clinical note that can be uniquely tagged, flagged, noted, and stamped in some way to demonstrate their individualism. Date stamping, time stamping, ID stamping, inclusion of patient pictures, or a unique summary sentence at the end of any narrative. No sooner do I write this and I expect to have a small army of physicians replying to this post telling me that I don’t know what I’m talking about. Further, adding time to the documentation process with seemingly silly CYA statements seems like a waste of time to everyone, myself included. So if we can automate many of these silly little CYA statements/actions within the documentation system itself, rather than having the physician tack on an additional 20 seconds of documentation per patient (multiplied by thousands of patients per year), maybe, just maybe everyone will be satisfied.

  3. As someone who used to do transcription and who now works for a software company, I find this laughable. When I did transcription, our pool had so many macros for our docs, who said the same thing day in and day out. These could (and are) easily inserted as templates in today’s EMR, and who could tell the difference? how they plan to enforce and how a physician would defend themselves against such accusations? I see what they are going after, thenold copy and paste, but why not let docs utilize shortcuts that every other business has at their disposal? Where is the line drawn between efficiancy and fraud? There are so many other clear cut places to go after abuse-this is not one of them.

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