Did Doctors Really Do What the Records Say They Did?

You may recall a couple of posts earlier this year on whether the relative value scale created by committees of the American Medical Association accurately reflected the actual time it took physicians to perform various medical activities.  Now we get research on whether the billing and medical records created by doctors accurately show what they actually did for a patient.   (JAMA Open Article)   The federal meaningful use program, another overhyped effort which hasn’t come close to meeting its objectives, has resulted in most providers using electronic medical records which in turn often feed billing systems.  So we have a lot more medical records in a supposedly much more accessible form.  Are they accurate?  There are incentives for them to overstate what physicians do, since this usually results in more revenue, and there are plenty of companies creating software and services to maximize documentation to obtain higher reimbursement.  In this study, the researchers observed what emergency room physicians did and compared it to the resulting medical records.  Their focus was the review of systems and physical examination portions of the patient interaction.  The observers were themselves trained in emergency room procedures.  The observers shadowed and recorded physicians during their shifts in the ER.  The researchers then compared the observed behaviors with documentation in the medical records.

The primary outcomes were comparing the documented number of review of systems with the observed number and comparing the reported physical examination with the observed one.  Nine physicians were included.  The median interaction was 6.6 minutes and a median 14 systems were documented as being reviewed.  Audio recordings and observations verified less than half of that number of reviews.  In regard to the physical examination doctors documented reviewing significantly more systems than observation suggested they actually reviewed.  The good news is that there was more concordance between documentation and observation in regard to the body systems relevant to the patient’s presenting complaint.  The physicians were aware of the study, so it is possible their behavior was affected, although you would think that would mean they were more careful.  Some of the inaccuracies are likely caused by auto-population features of EHRs.  CMS is considering revising what kinds of documentation it expects to see for reimbursement purposes.  That may be helpful for reducing unnecessary actions by doctors and improving the relevance of documentation.  This kind of study needs to be done more frequently.  The consequences for reimbursement are obvious but there also are quality of care implications, since other providers may be relying on erroneous information in the medical records.