EHRs and the Perils of Copy and Paste

November 28th, 2012

Connie Tohara smallGuest blog by Connie Tohara, Director of Health Information, University of Utah Hospital

The national election is over, and the implications for healthcare are many.  However, rapid change is not just on the horizon—it has been a part of the everyday life of the HIM professional for longer than we care to remember.  Over the years, we have had the introduction of DRGs, MS-DRGs, APR-DRGs, RACs, MACs, MICs, and ICD-10, just to name a few.  The core product that we work with—the medical record—is changing as well.  We find ourselves in a transitional world.  We’re dealing with the additional requirements of hybrid records and scanning. Workflows must change and productivity is always taking a hit from one new problem or another.

The latest problem to raise its ugly head came with a letter to hospitals released on September 24th under the signatures of Kathleen Sebelius, Secretary of the Department of Health and Human Services (HHS), and Eric Holder, Jr., Attorney General for the U.S. Department of Justice.  In part, it states:

…there are troubling indications that some providers are using this [EHR] technology to game the system, possibly to obtain payments to which they are not entitled…. These indications include potential “cloning” of medical records in order to inflate what providers get paid…A patient’s care information must be verified individually to ensure accuracy:  it cannot be cut and pasted from a different record of the patient, which risks medical errors as well as overpayments.

It’s clear from these statements and many more available online, such as the Office of Inspector General Work Plan for FY 2013, that CMS intends to audit for duplicative records and are defining the use of copy and paste as having a huge potential for fraud.

As HIM professionals, the use of copy and paste has long been a worry for us. We have dealt with the headaches of documentation being pulled from one place in a particular patient episode to another in the same episode, information being moved from a different episode of care for the same patient to the present episode, and, worst of all, language being pulled from one record into that of another patient altogether.  This use of copy and paste creates mix-ups in the sex, age, and other specific details of the patient’s illness or injury, and can raise the risk to patients exponentially, both for their current care and for future care when the past record is being used for decision making.

In addition, there is great pressure on physicians to document more thoroughly—to achieve appropriate reimbursement for services; to better demonstrate patient acuity; to provide detailed information for research and education purposes.  As increasing regulatory requirements negatively impact their time, they become frustrated and look to copy and paste as a way to speed up documentation.  Remember, they got into medicine to take care of patients, not take care of all the other things that are required.  I’m not saying that it’s the right thing for them to do, but there are powerful reasons for why they do it.

So how does the coder differentiate between original documentation and that which has been pulled from another place?  With today’s electronic health record technology, they can’t.  And that’s exactly what HHS and CMS are concerned about.  It’s time for something to be done.  Either we need to find a way to prevent copying and pasting from being done, or we need to find a way to make such documentation instantly recognizable to HIM staff so that they can protect their organization from potential charges of fraud.  If we can determine what is copied and pasted, we can avoid using that information to code for reimbursement.  Copy and paste is a hot topic in every EHR vendor’s User Group Meeting that I have attended for years, but we still don’t have a viable solution.

Now that the risks have gone up with the stance that HHS and the OIG are now taking, the need for solutions is greater than ever.  We need better guidance from government entities about how they are interpreting this new directive.  We need better ways to document effectively and quickly in the EHR without copy and paste.   And we need to get medical staff support to find solutions that work for us all.

Connie Tohara is the Director of Health Information at University of Utah Hospital.