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Thursday, July 01, 2021

The Cures Act,clinical notes and how one well known hospital system complies

 The Cures act mandates that health care providers (HCPs) provide patients access not to just their clinical records but also to the "clinical notes".This refers to the notes that a physician takes during or shortly after the clinical encounter.The initial physician resistance to giving up their clinical notes on the grounds that the patients might not understand the medical terms and jargon had largely dried up by the time that section of the Cures Act finally became in effect.  The Cure Act did much more than mandate that patients can access their clinical notes. The lobbying effort for bill passage was lead by representatives of big pharma and medical device manufacturers.The bill made drug and device approval significantly  easier.

The Act applies all HCPs,health information exchanges and certified IT developers. Fines of up to $1,000,000 you interfere or prevent access or exchange of electronic health information. 

The Act requires that requests for medical information be accomplished "without delay"

Now  as to how one large,big city,well known hospital system complies

We will call the hospital "well known famous place" or WKFP for short and examine how they move to comply with the Cures ACT.

I requested the clinical notes from my primary care internist and from my cardiologist, both of whom are within practice groups which are part of  the WKFP system. Within 48 business hours I received both sets of clinical notes in my patient portal.The shocking number of errors in my internist's clinical notes is a subject for another day.

The most striking feature was the description of a detailed physical exam which both physicians claimed they did but did not actually perform. The Internist's exam consisted of listening to my lungs and the cardiology doc  did not touch me at all. (The usual handshake was eliminated by Covid precautions.)

So the hospital system gets an "A" for delivery of the requested records but an "F" for providing a detailed record of examination that were fabricated. I can not  think of another word to describe claiming that a physical exam was done when in fact it was not. 

Is this done to document an exam to justify the level of Medicare charge they submit? Perhaps so, I cannot think of another reason. Do the physicians involved not worry about this practice? Have the shrewd corporate lawyers found a way to protect this practice from being deemed Medicare Fraud?To my legally naïve eye charging for services not provided would appear to be fraud.(The 20210 changes in Medicare coding seemingly has decreased keying on the exam to upcode visit so maybe there may be no reason to fabricate a physical exam.Maybe that is left over from earlier coding games.)

I have been aware of this ghost exam practice before and have blogged about it. See my blog entry with following title "Has the modern electronic medical record made many physicians accomplices to lying?" Two family members underwent colonoscopies at different hospitals.In both cases the attending physician included in his endoscopy report a detailed physical exam which never happened. Another family member underwent a arthroscopy and appended to that report was the physical exam that was not done by the orthopedic surgeon.

IMO  the modern medical record with all of its electronic snazziness has devolved to be a  embarrassing collection of misinformation, errors and fabricated exams. On the positive side the patient now has a powerful tool-the Curres Act provisions- to obtain his medical record , warts and all. 

addendum: 7/10/21 I had a echocardiogram at 8:am on Thursday. by Friday at 8:p, I received a text that I had a new test results in my patient portal.It was a full report of the echo replete with the data not just the summary. 

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