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The Role of Copy-and-Paste in the Hospital Electronic Health Record

The Role of Copy-and-Paste in the Hospital Electronic Health Record

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Published by HLMedit
The Role of Copy-and-Paste in the Hospital
Electronic Health Record
The Role of Copy-and-Paste in the Hospital
Electronic Health Record

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Published by: HLMedit on Aug 07, 2014
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08/29/2014

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Copyright 2014 American Medical Association. All rights reserved.
TheRoleo
Copy-and-Paste 
intheHospitalElectronicHealthRecord
Beforeelectronichealthrecords:
If you did not docu-ment it, you did not do it.
Afterelectronichealthrecords:
Youdocumentedit,but did you do it? 
After a slow start, hospitals in the United Stateshave rapidly adopted electronic health records, asencouraged by the Health Information Technology forEconomic and Clinical Health Act of 2009 (HITECH).
1
By May 2013, more than 3800 hospitals, or about80% of the hospitals that were eligible, had receivedincentive payments from the Centers for Medicare &Medicaid Services (CMS) related to the adoption,implementation, upgrading, or “meaningful use” of theserecords.
2
Yettheapplicationofelectronichealthrecords can be a double-edged sword. Their use canincrease efficiency, facilitate information sharing,standardize hospital processes, and improve patientcare
1,3,4
Buttheirusecanalsohaveunintendedconse-quences and be subject to abuse, such as when dataare duplicated or templates and checkboxes are usedto generate standardized text without a good medicalreason.Theduplicationofdataintheelectronichealthrec-ordfromonelocationtoanotherisknownas“cloning”
5
or“copy-and-paste”
3,6
andmaymoregenerallyrefertomultiple features, including autopopulate and tem-plates and checkboxes that generate standardizedtext. Copy-and-paste is related to, yet differs from,“overdocumentation,”
3,6
thepractice“ofinsertingfalseor irrelevant documentation to create the appearanceofsupportforbillinghigherlevelservices,
3,6
aswellas“upcoding,”
5
theassignmentofaninaccuratebillingcodetoamedicalprocedure,treatment,orvisittoinflatere-imbursement.InSeptember2012,federalofficialswarnedabout“the misuse of electronic health records to bill for ser-vicesneverprovided,
5
andthatlawenforcementagen-cies“willtakeactionwherewarranted.
5
Tworecentre-ports from the Office of Inspector General of theDepartment of Health and Human Services (OIG) ana-lyzedhowelectronichealthrecordtechnologycanmakeit easier to commit fraud and found deficiencies in theimplementationofrecommendedsafeguards.
3,6
Theof-fice recommended that the CMS develop a “compre-hensiveplantoaddressfraudvulnerabilities”
3
andpro-videguidancetohospitalsontheuseofcopy-and-paste.
3
TheOIGalsorecommendedthatCMSinstructitsaudi-torstodetectfraudandthatauditlogsthatdetectdu-plicatedtextbeoperationalizedandusedbyCMScon-tractors to assist in fraud detection.
3,6
Although thefederalgovernmenthasfocusedonhospitals,themis-use of copy-and-paste in office-based physician prac-ticeswouldraisesimilarissues.
DoestheUseofCopy-and-PasteEqualFraud?
Clearly,technologymakesiteasiertocommitfraudwhenphysicians use tools such as copy-and-paste or tem-platesinappropriately.Theuseofthesefeaturesmayalsocontribute to poor quality in clinical notes. For in-stance,asocialhistorycopiedandpastedintoanadmis-sionnotemayindicatethatapatientwhoisacandidateforalivertransplantisstillconsumingalcohol,wheninfactthepatienthasbeensoberformonths.Aphysicianusing templates and prefilled checkboxes may care-lesslydocumentacompletephysicalexaminationbyde-fault when he or she only conducted a more limitedevaluation.Withtheerroneoususeofcopy-and-paste,thephysician’sassessmentandplanmaydocumentade-cisiontostarttreatmentwithantibiotics“todayforsev-eraldaysinarow,beforethemistakeisrecognizedandcorrected.Yet these same features of electronic health rec-ordscanbeefficientandclinicallyusefulwhenusedprop-erly.Althoughtraditionalhandwrittennotesmayoftenhavebeenmoreconciseandexclusivelyservedaclini-calneed,thepurposesofaphysicians’noteshavebeenbroadenedbytheiruseforbilling,tofulfillregulatoryre-quirements,suchascompliancewithfederalstandardsforthemeaningfuluseofcertifiedelectronichealthrec-ordstechnology,
4
andtocollectdataforuseinstandard-ized measures of quality. For example, a core measureofmeaningfuluseisaproblemlistofcurrentandactivediagnosesthatallphysiciansupdateanduse.Unlesstheproblemlistchanges,itshouldbeidenticalineachnotethat refers to it. Time spent in “counseling and coordi-nationofcaremayappearinatemplatetoremindphy-sicianstodocumentthetimespentwiththepatient,nottoupcodebuttosupportpaymentforactualcarepro-vided. A template or checklist for the care of a patientwithmyocardialinfarctionmayhelpthephysiciantore-membertoprescribeaβ-blockerortooffersmokingces-sationcounseling.Andifasuccessfulcholecystectomyhappensinexactlythesamewayfor3consecutivepa-tients,theaccompanyingidenticaldocumentationofthesurgicalproceduresshouldbewelcomed.Thefederalgovernmentusesarangeoffederallaws,including the False Claims Act, in detecting and pros-ecutinghealthcarefraud.
7
Whencopy-and-pasteisused,fraudisaconcernwhenthedocumentationisknowntohavebeenduplicatedorcreatedpriortotheepisodeof care for which reimbursement is claimed. Yet it is tooeasy, and often mistaken, to equate a physician’s rou-tineuseofcopy-and-pastewithfraud.Datareplicationisafeatureofelectronichealthrecords;factsbeyondthemereuseofduplicatedtextarerequiredtoestablishthatanotemaybefraudulent.Anyprocessbywhichcareisdocumented
could 
befraudulent.However,noprocess
VIEWPOINT
AnnM.Sheehy,MD,MS
DivisionofHospitalMedicine,DepartmentofMedicine,UniversityofWisconsinSchoolof MedicineandPublicHealth,Madison.
DanielJ.Weissburg,JD,CHC
UniversityofWisconsinHospitalandClinics,Madison.
ShannonM.Dean,MD
DivisionofPediatricHospitalMedicine,Departmentof Pediatrics,Universityof WisconsinSchoolof MedicineandPublicHealth,Madison.
CorrespondingAuthor:
AnnM.Sheehy,MD,MS,DivisionofHospitalMedicine,DepartmentofMedicine,UniversityofWisconsinSchoolof MedicineandPublicHealth,1685HighlandAve,MFCB3126,Madison,WI53705(asr@medicine.wisc.edu).
Opinion
 jamainternalmedicine.com
 JAMAInternalMedicine
 August2014 Volume174,Number8
 1217
Copyright 2014 American Medical Association. All rights reserved.

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