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March 14, 2011

The Perils of Copy-Paste
By Alice Shepherd
For The Record
Vol. 23 No. 5 P. 14

Providers who follow the mold to populate electronic patient charts are at risk of producing inaccurate medical records.

Copy-paste, copy-forward, macros, defaults, and templates are handy time-savers for physicians who don’t enjoy typing paragraphs to populate patient EHRs. However, hidden dangers lurk within these shortcuts, enticing unwary providers into producing documentation that can be confusing at best. At worst, the maneuvering could violate HIPAA privacy rules, invite federal and payer audits, and leave doctors vulnerable to accusations of fraud and malpractice.

It’s important that HIM professionals understand these risks so coders, analysts, and others who review records can spot the red flags of misuse. HIM is in the best position to spearhead the development of documentation guidelines and training programs to educate providers on the appropriate use of copy-paste and related functionalities.

Where Copy-Paste Gets Sticky
“Many providers use the computer’s built-in Windows function to select text, such as notes or discharge summaries, and copy it to a note on another day, another part of the record, or even another patient’s chart,” says Diana Warner, MS, RHIA, CHPS, a manager of professional practice resources at the AHIMA. “Sometimes they copy information that is no longer relevant, which can affect patient care. Or they copy too much, such as pages and pages of labs. Instead of a succinct paragraph or page of information, you then get a confusing ‘note bloat,’ and the next provider treating the patient can’t figure out what’s new, what’s relevant, and what’s no longer an issue.”

A particularly risky practice is copying from one patient’s record to another, says Warner, because it can result in a HIPAA violation if the copied text includes the original patient’s identifiers and the record is released.

At Exempla Healthcare, Karen Proffitt, RHIA, CHP, HIM system director for EHR, has observed misuse of the Windows copy-paste function by providers who don’t understand what needs to be documented in a legal medical record. “For instance, they sometimes proliferate their progress notes with all kinds of information that really doesn’t need to be included, which makes the record less transparent and difficult to understand,” she says. “Similarly, physicians who have an ambulatory EHR system in their offices sometimes copy an entire office visit and paste it into the hospital system as a history and physical. Unfortunately, they don’t just copy pertinent elements but also other office-related notes. The resulting hospital record lacks succinctness while sometimes missing critical elements that should be included.”

Another serious patient care issue arises when copied text includes errors. “Say, for example, a provider inadvertently stated the patient needed surgery on the left arm,” says Warner. “He later corrected it to right arm but, by that time, the note with the error may already have been copied by other providers or have traveled to other systems via EHR interfaces.”

The copy-forward functionality included in some EHR systems invites similar problems. “Many products create a copied note that cannot be differentiated from information that was newly entered by the provider, which can result in a wide range of malpractice and patient care issues,” says Ronald Sterling, author of The Keys to EMR/EHR Success: Selecting and Implementing an Electronic Medical Record. “When providers cite forward an entire note, that could easily misrepresent the level of service that was provided, and the E&M [evaluation and management] coding might therefore be incorrect. As important, the provider cannot determine which findings were newly entered and which findings may need to be reviewed. In fact, the OIG [Office of Inspector General] General Work Plan for 2011 has listed identical notes as an area of interest. Payers, too, who keep seeing identical notes for patients may call into question whether the work was really done.”

“A Columbia University study published in 2010 reviewed histories and physicals created by residents and found that in two different types of medical charts, 54% and 78% of the words were identical in chart after chart after chart,” says Stephen Levinson, MD, author of Practical E/M: Documentation and Coding Solutions for Quality Patient Care and Practical EHR: Electronic Record Solutions for Compliance and Quality Care. “It’s basically the equivalent of using a rubber stamp on a paper chart. In medical school, we defined a lecture as a process by which information passes from the notes of the professor to the notes of the students without passing through the minds of either. Similarly, when you have a single click, there is a propensity for information to pass from one part of a record to another without passing adequately through the mind of the observer.”

Levinson has observed that during follow-up visits, providers may copy-paste or copy-forward past, family, and social history from the first visit in lieu of documenting the course of the illness since that time. Then they claim that they asked all the questions again even if they did not.

Physical exam results may also be copied and pasted with dire consequences. “In one case, when a patient complained to a state licensing board about charges for a comprehensive visit and exam by her doctor’s office when she had not even been asked to disrobe, investigation revealed that the doctor’s electronic record documentation resulted from pushing a button to copy and paste a normal exam for each visit,” says Levinson. “The state licensing bureau concluded that the medical record misrepresented the care performed.”

Recognizing the dangers of copy-paste misuse, EHR vendors have provided alternative functionalities such as default content, templates, and macros. “For example, providers who find that many or all areas of a physical exam are normal can use defaulting content to mark all the body systems examined as normal,” says Keith Slater, general manager and vice president of Henry Schein MicroMD. “They can then document specific findings by exception rather than having to manually mark/address every area of the exam. A template can be structured as a comprehensive guide or road map providers can use to document patient encounters. It walks them through the type of information they would normally collect and reminds them of the different areas to address so they can document a thorough care plan, get credit for their work, and bill accurately for their services. Templates can be specific to certain body parts and conditions or can be all-inclusive master templates that allow a general practitioner, for example, to navigate into any part of the body.”

Push-Button Medicine?
The problem with macros is that providers sometimes neglect to check whether all the preloaded answers apply to a particular patient encounter. “Hypothetically, providers are supposed to ‘undocument’ or delete questions that were not asked and redocument responses that differ from the preloaded ones,” says Levinson. “However, providers who have tried to use macros correctly in this manner find that it takes them 50% longer to document using that approach than to work from scratch, so many just push the button and create nonspecific automatic documentation.”

“Using note templates, just like citing forward, opens the risk of making a representation about patient care that was not based on the specific office visit,” says Sterling. “In other words, the template or cited note may not have been fully corrected by the physician who signed it, which could expose the practice from a malpractice standpoint. Unfortunately, many EHR approaches turn everything from a clinical problem into a technology issue. We accede control to technology and change our processes accordingly rather than marshalling technology resources to support our processes and benefit patients.”

On top of those risks, there’s the matter of creating an accurate narrative of patient care. “Misuse of any copy-paste functionality, including macros, also corrupts the documentation of history of present illness,” says Levinson. “Rather than the required chronological description of the course of the patient’s illness, we’re finding electronic medical notes that read essentially as an elaborate chief complaint. Information critical to patient care is not being elicited because the preloaded macro disrupts and corrupts the physician’s normal workflow and diagnostic processes.”

Can EHR vendors help alleviate the problem? Levinson says the marketplace probably won’t allow it. “Vendors who strive to create effective, efficient, usable, compliant, and patient care workflow-positive histories and physicals still feel they cannot remove copy-forward and related functionalities from the data-entry armamentarium because competing vendors will then market their systems as doing it even faster,” he notes. “AHIMA and other organizations have published multiple articles condemning the intrinsic noncompliance of cloned documentation created by a variety of noncompliant data-entry functionalities, all of which lack the ability to obtain as well as document a true history of present illness.”

The issue becomes even more critical when you consider the emphasis federal auditors are placing on spotting fraud and abuse cases. “At the top of the OIG’s hit list for 2011 is E&M compliance, including documentation using EHRs,” says Levinson. “Physicians are treated to $44,000 for using EHRs meaningfully, but the OIG could fine them $150,000 or more for using their noncompliant documentation shortcuts.”

“Many EHR vendors market what they think will help physicians’ notes meet E&M requirements so they can get the ‘brownie points’ for a certain level of service,” says Sterling. “Rather than documenting that something is within normal limits, they identify five different components of the area within normal limits. That’s the underlying industry requirement that drives some of these design factors. For example, the doctor examines a patient’s hand [for] texture, tautness, color, mobility, and temperature and then checks five boxes even though those things were examined simultaneously. The question is, does the provider know what is being represented?”

Is there a place for copy-paste in compliant documentation? “I see no role for copy-paste, copy-forward, or documentation by exception in the medical history or the physical examination,” says Levinson. “It cannot be done compliantly or compatibly with quality care.” When it comes to past, family, and social history and review of systems, he suggests physicians can save time by having patients complete forms using a digital pen that uploads information into the EMR. The physician then only needs to review the information and drill down with questions.

“Copy-paste can be a valuable asset in documenting the medical decision-making component of E&M care,” says Levinson. “For instance, it can be used to transpose lab results and radiology findings into the data part of the history and physical as long as providers attest that they have reviewed these reports and comment on them. Macros can also be useful, for example, to select which tests to order from a standard preloaded set. Copy-paste is also appropriate in the problem list; when a patient returns, the physician can bring up the existing list and check off the problems that are pertinent to today’s visit as well as add new items.”

Policies and Procedures
In light of the many concerns surrounding the use of EHR shortcuts, providers must take steps to ensure compliance measures are being met. “Each healthcare organization has to decide on appropriate use of the EHR, establish management policy to govern and empower compliance, implement audit and control structures to enforce the standards, and provide training,” says Sterling. “Compliance should be part of the provider evaluation. Additionally, they have to engage in discussions with vendors on features such as confirmation of findings that will mitigate the risks of copy-paste functionalities. Further, while providers should look for software whose set-ups are tailored to their area of medicine, they have to realize that those setups may be making clinical documentation decisions for them. They have to understand who created the ‘standard’ templates they’re using because, in many cases, they were not developed by the organization or practice but by the vendor. However, the practice is responsible for the representations being made.”

“Abuse is usually unintentional and results from lack of awareness,” says Slater. “We clearly explain to our customers that they can turn on or off the default answers. Providers need to take the time to understand how their system works and that it is only a tool to help them collect the data based on the workflow they have shared with us. Ultimately, they are the ones making the medical decisions.”

To populate the EHR without the need for typing or the use of templates and macros, Slater suggests using voice recognition technology. “This enables providers that may normally dictate notes to continue that familiar process but have voice recognition software transpose their voice to text within the EMR,” he says. “Macros for quick entry of repetitive clinical phrases can be utilized with voice recognition as well. Final notes can be reviewed by an editor or transcriptionist, by the providers themselves, or by others but are immediately available for review during this process, so there isn’t a waiting period as there may be with a transcription service.”

Exempla Healthcare has recently developed copy-paste and documentation guidelines. “They outline basic documentation tenets and explain the inherent problems with copy-pasting,” says Proffitt. “They alert providers to the risks of giving the wrong impression, unintentional charting, lack of authenticity, propagation of false information, unnecessarily lengthy progress notes, and billing and fraud abuse concerns. Providers are cautioned that their notes should accurately reflect the work being done and that they are responsible and accountable for all the data in a note, whether they dictated it or copy-pasted it.”

The guidelines, which were distributed during EHR go-live training and are currently being piloted during residents’ training, may be formalized into policy and used to train all attending physicians.

When developing rules for governing EHR shortcuts, Warner says it’s important to involve the pertinent departments, and training should be a priority. “A multidisciplinary team, including HIM and risk management, should develop clear policies, rules, and instructions for using copy-paste functionality appropriately,” she says. “There should be repeated education as well as sanctions for misuse. If there have been previous litigation or reimbursement issues as a result of improper documentation, trainers should cite those examples. It’s also important to understand why physicians are using copy-paste. Is it because the EHR software is too cumbersome and labor intensive? The system should be working for the physicians, not the other way around. Be flexible in offering alternatives to physicians, such as voice recognition software or the use of scribes.”

Meanwhile, HIM professionals are at the forefront of the battle to identify and stamp out abuse. “Rather than adding another layer of resources to audit records, it’s very important that we encourage chart analysts, coders, and others who are reviewing charts to help highlight potential problems,” says Proffitt.

“Be proactive and conduct audits,” says Warner, who admits this can be difficult because there often is no audit trail with copy-paste.
“Ultimately, there needs to be a process in a medical practice to audit the electronic data-entry process periodically,” says Slater. “If patient charts were never audited except by Medicare, Medicaid, or an insurance company, it would be like posting financial information in a practice management system without ever running reports to ascertain balances and ensure data integrity. Someone has to spot-check the providers’ data entry, the consistency of their notes, and whether they are documenting the elements of an exam to submit the proper billing codes. This is where the clinical knowledge of HIM professionals should be leveraged.”

— Alice Shepherd is a southern California-based business-to-business journalist specializing in healthcare topics.