Gastroenterology Coding Alert

Question: We’ve read several articles in Gastroenterology Coding Alert about the dangers of using electronic health record templates, but we aren’t sure why they’re bad. What’s wrong with them?

Connecticut Subscriber

Answer: Templates in electronic health records (EHRs) may help save time, but they can also create issues for some practices. Many EHR templates were designed in part to assist providers in efficiently documenting the medical record. However, some of the templates do not appear to be correlated with a providers’ clinical intuition and tend to hinder productivity.

Pre-built templates contain mandatory fields of text that should be deleted if the provider is adding their own information about the patient’s chief complaint, symptoms, or histories. This can be an issue with the free text entry option on the EHR.

EHR errors were said to be more common during the shift to the 2021 Office and Outpatient Guidelines, which are focused on medical decision making. Updating the EHR templates for E/M visits to suit these guidelines is difficult since fulfilling the requirements for E/M visits is a more clinically intuitive process for providers.

Is help on the way? Typically, one or two education sessions and periodic coding reviews help solidify providers’ comprehension of the guidelines and facilitate implementation to their documentation.