19 Sep How Often Does Doctor’s Note Match What Happens in Exam Room?
MedicalResearch.com Interview with:
Carl Berdahl, MD, MS
Emergency Physician and Health Services Researcher
CEDARS-SINAI
West Hollywood CA
MedicalResearch.com: What is the background for this study?
Response: The length of a doctor’s note is taken account when determining how much a doctor or medical center is paid for a visit. However, in the digital era, a doctor can generate large amounts of text with just a few keystrokes. Given this incentive structure, we were concerned doctors’ notes might be inaccurate in certain sections of the chart that are important for billing. We used observers to determine how accurately doctors’ notes reflected the interactions between patients and physicians.
MedicalResearch.com: What are the main findings?
Response: In a sample of 9 licensed emergency physicians practicing simultaneously at two medical centers, we found that about 50% of the content of doctors’ notes was inaccurate.
MedicalResearch.com: Which parts of doctors’ notes were most likely to be flawed?
- In the Review of Systems section, the doctor keeps track of a patient’s answers to yes/no questions, such as “Do you have a fever” or “Do you have any shortness of breath”? The accuracy of this section was 38.5%.
- In the Physical Examination section, the doctor describes the findings after examining a patient. For example, if a doctor listened to the patient’s lungs, the lung section of the physical examination might read “lungs are clear”. We found the physical examination section to be 53.2% accurate.
MedicalResearch.com: Are these problems with documentation likely to cause harm to patients?
Response: Based on our results, we believe that harm is possible but rare. We found that accuracy was best for areas of the body that were most important to the patient’s reason for visit. For example, if a patient sought attention for abdominal pain, the physician was very likely to perform and document and abdominal exam. For the same patient with abdominal pain, a documented ear examination was less likely to be accurate.
MedicalResearch.com: In what ways exactly are the billing requirements incentivizing doctors to record their experiences incorrectly?
Response: For a complex patient’s case, such as for a patient who is having a heart attack, it is necessary to write a lengthy chart in order to obtain the deserved reimbursement. Most doctors would agree that I only need to examine, let’s say, 5 or 6 body systems for a patient with a heart attack to do a comprehensive evaluation. But the billing requirements necessitate that I need to document that I examined 10 body systems so that I can get paid, appropriately, for a complex visit.
MedicalResearch.com: Is it accurate to say that most of the discrepancies involved doctors overstating rather than understating the services performed—and thus overbilling rather than under billing?
Response: Nearly all the cases we studied involved overdocumentation rather than underdocumentation. We made the decision not to study billing, so I can’t be sure whether these cases involved overbilling.
MedicalResearch.com: This study involved just 9 doctors who volunteered to be in the study and who knew they were being observed. Is this problem more widespread and perhaps worse than the study found?
Response: While our study involves a small sample, we have discussed our results with doctors around the country. Based on these conversations, I believe that this may be a nationwide issue, but further study will be needed.
MedicalResearch.com: What are your two institutions, UCLA and Cedars-Sinai, doing to address this problem?
Response: Both UCLA and Cedars-Sinai are planning research exploring new ways to produce documentation that is more accurate and less burdensome. We believe that having patients contribute their own written history to the medical record would be a move in the right direction. Also, we are interested in using multimedia to make an objective record of the encounter that patients and doctors could refer to after the visit. For example, an accurate transcript of the encounter produced from the audio could be much more valuable for patients than the current system.
We want to free doctors of the current burdens of documentation so that they can spend more time at the bedside getting to know their patients and addressing patients’ concerns. Unfortunately, current billing rules constrain innovation in this space, so we hope the results of this study will encourage Medicare to reform the rules and allow innovation that brings doctors and patients back together.
Any disclosures:
Dr. Schriger, Vice Chair of Emergency Medicine and the senior author for the study, is on the editorial board of the parent JAMA journal.
Citation:
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Last Updated on August 12, 2024 by Marie Benz MD FAAD