Do EHRs promote fraud?

February 8, 2008
Robert Lowes

Bob has reported on the medical profession since 1988, covering everything from HMOs to end-of-life controversies. He now specializes in practice management issues and writes the magazine's Tech Talk column. Bob has received awards for his work from the

Contrary to conventional wisdom, EHRs could reduce the quality of care and increase costs, says a pioneer in healthcare information technology.

Contrary to conventional wisdom, EHRs could reduce the quality of care and increase costs, says a pioneer in healthcare information technology.

If anybody believes in the potential benefits of electronic charts, though, it’s internist Donald Simborg. He created HL7, the computer protocol for exchanging electronic health data, and founded a company that makes EHRs for oncologists, among other accolades.

Yet in an article scheduled to appear in the March/April edition of the Journal of the American Medical Informatics Association, Simborg writes that growing EHR adoption may not be in our best interests. EHR vendors, he states, sell doctors on the idea that their products will save them time and increase revenue through higher evaluation and management coding. However, these incentives are problematic, in part because higher E&M coding boosts overall healthcare costs, according to Simborg.

He states that it’s not clear whether higher coding represents a correction of undercoding or “a form of E&M code creep.” The latter may be the case, Simborg suggests, since an EHR-equipped doctor can quickly create voluminous chart notes with a few mouse clicks by copying a previous note or using default templates.

“Unfortunately, because physicians are paid on the basis of what they document, the defaults built into most systems tend to be the maximum documentation of what they normally do rather than the minimum,” writes Simborg. While such easy-do notes increase E&M coding and revenue, they pose a threat to patient care. Why? Because computer-generated documentation may describe things that never actually happened in the exam room, according to Simborg.

Simborg has a special interest in the subject of dubious documentation. He co-chaired a blue-ribbon IT committee that recommended to the U.S. Department of Health and Human Services that it build sufficient anti-fraud mechanisms into the national health-data network envisioned by the Bush administration.  One example of fraud spotlighted in his committee’s 2005 report to HHS was “upcoding and misrepresentation of treatment,” although the report noted that only a small minority deliberately commit such acts.

In his JAMIA article, Simborg states that while creating safeguards against EHR fraud might strike physicians as threatening and slow down the adoption of this technology, it’s still worth doing. Writes Simborg: “Adoption, per se, is not the goal.”

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