Like most things tech-related, the terminology surrounding this common EHR function can be confusing. Copy-and-paste is often used interchangeably with other terms like copy forward, cloning, and cut-and-paste. They all refer to reusing text from one patient record in another record.
This isn’t usually a problem for historical patient data that is stable and unlikely to change, like family and social history, allergies, and prior surgeries. The problem occurs when visit-specific data is copied from one note to another, like the chief complaint, diagnostic testing, review of systems, and treatment plan.
“The cut-and-paste function allows providers to enter relevant information into a patient’s medical record more efficiently, which saves time on typing and leaves more time for patient care,” says attorney and healthcare compliance expert Michaela D. Poizner. But “relevant” is the key word. “Providers have to be careful that they don’t accidentally copy inaccurate information into a patient’s record,” Poizner continues.
4 Common Copy/Paste Errors
Sloppy copy/paste habits can lead to four general types of errors, according to David Silverstone, MD, who spoke to ophthalmologists about EHR compliance and medicolegal issues at AAO 2016 and 2017.
These occur when the time elements of a visit are incorrect. For example, a procedure was performed during one visit, the note is copied, and it appears that the same procedure was performed at a subsequent visit (it wasn’t).
These occur when information in one part of the note is at odds with other information in the note. Silverstone gives the example of a copy-and-pasted chief complaint of decreased visual acuity. However, in a different part of the note the patient states that vision is slowly improving.
This occurs when it’s unclear who wrote parts of the note (i.e. physician, tech, or scribe).
Omission of Material Facts
This can occur when relevant data gets buried in long, cut-and-pasted notes.
3 Ways Copy/Paste Could Hurt Your Practice
If your copy/paste habit has gotten out of control, you could be doing real damage to your practice’s financial health—and to your patients. “Careless cutting and pasting that compromises the accuracy of a patient’s record could hamper a provider’s ability to effectively treat the patient. Inaccurate patient records can also lead to inaccurate billing, if claims are generated directly from the EHR,” Poizner warns. Below, three very real consequences:
You’ve likely heard coding and billing experts say ‘if it’s not documented, it didn’t happen.’ But when it comes to cloned notes, the opposite is true: just because it is documented, doesn’t mean it did happen.
Patient-specific information to support medical necessity for tests or procedures could get lost when information is cloned in EHRs, leading to medical necessity denials. You’ll have to dedicate resources (staff time and money) appealing those denials. And if an auditor discovers inappropriate cloning, you’ll need to return any overpayments.
Auditors are looking for two red flags, according to Zachary S. McCarty, OD, who presented at the 2017 SECO conference in Atlanta:
- Records on the same day stating the same thing
- Records from consecutive visits stating the same thing
Patient records “must be specific to the patient and to the date of service,” Mc Carty notes. Providers must be “mindful that records reflect THAT visit, [and] be careful to ensure [the] record says something specific about the patient at that visit,” he emphasizes.
The increased volume of copy-and-pasted EHR records could make it difficult to distinguish critical findings from background data. In turn, that could adversely impact a physician’s ability to effectively treat the patient. Risks include misdiagnoses, medication dosing mistakes, and patient injury. More than 80 percent of EHR-related malpractice claims involved moderate or severe patient harm, according to a study from the Agency for Healthcare Research and Quality published in the November 2015 issue of the Journal of Patient Safety.
“Copy forward can copy legacy data that is not relevant to today,” says Silverstone. And “quantity of information increases and can produce information overload—chart bloat,” he continues. “We need to avoid including data that is irrelevant to the current exam—especially notes created at previous encounters with the patient.”
Most troublingly, copy-and-paste can lead to violation of the False Claims Act. Copying notes from a prior visit could lead to upcoding, or coding a visit as more comprehensive than it actually was. Or, services from the past visit might be copied to a subsequent visit, even though they weren’t performed. This results in a fraudulent submission for reimbursement. That’s because it misrepresents the patient’s visit or leads to billing for services and test that did not occur. Remember, proof of intent to defraud is not required under the False Claims Act. Deliberate ignorance or reckless disregard is sufficient.