Watching a high school football game, one where we were hopelessly outmatched, I watched the visiting team score time after time, rendering the parents of our players, very quiet.  When the silence had become almost too much to bear, one of the parents yelled,”CHEATERS!”  I found this extremely funny, defiant to the end, discounting the victory of the opponent and one of the most clever and humorous things I’ve ever witnessed.  While his cry of “cheaters” was gratuitous and meant to be funny, this blog about cheaters is not.

One of the purposes of EMR (electronic medical records) systems in hospitals is to maximize revenue.  Certain tests or consultations (nutrition consultations, for instance) bring revenue far in excess of the resources needed to provide this service and are therefore extremely profitable.  One of the ways these systems can be used to pad the profits of these “not for profit” hospitals is enabling something called a “level 4” exam, an intensive patient examination for which the government and others will pay top dollar.  This unscrupulous practice embraced by some large hospital systems goes like this:  every day one of the hospitalists (hospital employees that will be referred to for the rest of this blog as “CHEATERS”) checks all of the necessary boxes on the EMR form to indicate that they have performed a complete history and physical exam (level 4) on every patient in the hospital, each and every day.  Now I want to be very clear.  What these CHEATERS are doing and what they say they are doing are two different things.  That’s what makes them CHEATERS.  What they are billing for and what they ought to be billing for are two different things, as well.  This, in particular, makes them CHEATERS.  In their defense, though, they are, like good little hospital soldiers, doing what they are told.  

I want you to understand exactly what I mean.  Put yourself in the patient’s place for a moment.  Imagine that every single day, the CHEATER shows up in your room and spends a solid hour going over every system of your body.  ”Do you have a family history of diabetes since yesterday?”  ”Are you a heavy drinker or a social drinker since yesterday?”  ”Are you still a widow since yesterday?”  ”Have you ever had asthma or a heart attack since yesterday?”  The insanity of this conversation is obvious, yet that is  the interview the CHEATERS claim to have done.  Now the exam.  ”Now I am going to check all of your cranial nerves, entire circulatory system, check your entire body for lymph nodes or masses and, well, you know, you’ll get your daily rectal exam, too.”  The truth is that the CHEATERS are spending about 2 minutes with each patient, the rest of their time being spent on a computer at the nurses station (cutting and pasting the prior day’s info and exam), fabricating a medical record, the primary purpose of which is to generate the maximum revenue for their boss.  Their focus in on the record, not on the patient.  

One of the purported benefits of EMR systems is that the patient’s records are portable, that is, a specialist, for instance, sitting in their office can view the patient medical record from a great distance.  But because of the big hospital EMR systems and the CHEATERS they have hired, all of these records look the same.  Pertinent and meaningful information, potentially life-saving information if present at all, is camouflaged by meaningless drivel, the vast majority of which exists to pad the hospital bill.  This brings me to my point.  These meaningless patient records, each indistinguishable from the next, rather than impart important patient information, conceals it.  I believe the results will be complications and deaths for hospitalized patients like never before.  Vast and numerous patient disaster stories will not bring an end to this insanity, but rather will result in government oversight, Senate hearings and new accreditation agencies, along with mandating jobs in hospitals for Medical Record Safety Management and Compliance Specialists.  Some ambitious nurse bureaucrat will salivate at the prospect of getting the MRSMCS initials after her name. 

Recently, a surgeon told me a CHEATER referred a patient to him for an abscess in their throat.  The physical exam section of the CHEATER’S EMR included a “normal” check for “throat exam.”  This means exactly what you think it does.  The CHEATER never looked at the throat, or if they did, the medical record is meaningless.  Discounting the accuracy or legitimacy of the hospitalized patient’s medical record is an unavoidable consequence of the introduction of EMR systems.  Watch for more and more government-funded “studies” showing the cost savings and enhanced patient safety hospital EMR systems have introduced.  Just as the EMR provides camouflage for the patient’s true condition, these “studies” will attempt to hide the human death and suffering resulting from their use.

G. Keith Smith, M.D.