Question

Discussion: Health Record Content and Documentation

Overview:

As a HIM professional within Anywhere Hospital’s HIM department, you have been asked to review physician documentation within the hospital’s new EHR system, implemented six months ago. Your goal of the review is to catch any documentation issues early and work with the appropriate hospital leadership to fix those issues.

As you review the documentation within your facility’s EHR, you notice that physicians are utilizing the copy and paste functionality available within the EHR system, allowing physicians to select health record documentation from one source or from one section of the EHR and replicate it in another source or another section of the record. You notice in one particular instance that the health record identifies a patient as a 65-year-old male (as identified during the registration process), but in the progress notes is described as a 25-year-old female who has given birth. Clearly, the physician utilized the copy and paste functionality inappropriately and copied health record information from a health record of a patient who was a 25-year-old female and pasted that information accidentally into a health record of a 65-year-old male.

You find this concerning because this could have patient safety concerns, as well as billing and claims issues and the use of this functionality could open the facility up to potential claims of fraud and abuse by the payer. You take this concern to your leadership and a multidisciplined group of hospital employees including HIM professionals, nurses, physicians, and billing and revenue cycle employees to discuss and fix the problem. There are mixed opinions about the copy and paste functionality. Some individuals feel this feature is a time-saver and a productivity booster while others believe it only opens the hospital up to additional CMS scrutiny.

Instructions

Respond to each of the three discussion topics.

What should be considered when deciding whether or not to use the copy and paste functionality? Why?

What controls might be put in place related to the copy and paste functionality? How effective could these be?

What alternatives to the copy and paste functionality are available? What are the pros and cons associated with each option?

Answer 1

What should be considered when deciding whether or not to use the copy and paste functionality? Why?

To address the use of “copy and paste” (there are other terms used such as cloning and carrying forward, identical documentation, or make me the author) functionality in electronic health record systems (EHRs). Use of the copy and paste (copy/paste) functionality in EHRs can result in redundant, erroneous, and/or incomprehensible health record documentation. Misuse of this functionality has the potential to result in or contribute to several overarching challenges, with implications for the quality and safety of patient care, medico-legal integrity of the health record, and fraud and abuse allegations. The use of copy/paste functionality in EHRs should be permitted only in the presence of strong technical and administrative controls which include organizational policies and procedures, requirements for participation in user training and education, and ongoing monitoring. Users of the copy/paste functionality should weigh the efficiency and time savings benefits it provides against the potential for creating inaccurate, fraudulent, or unwieldy documentation. To ensure appropriate use of the copy/paste feature in EHRs and reduce risks associated with improper design and use.

Copied and pasted notes may lead to a number of unintended consequences. First, copy/paste might interfere with or compromise communication among the members of the care team. Second, there are implications for the quality and safety of patient care such as medical errors resulting from inaccurate or outdated clinical information. Third, the medico-legal integrity of the health record is potentially jeopardized because information overload can cause clinicians to miss important pieces of information and medical errors can occur as a result of inaccurate information. Finally, the inappropriate use of copy/paste may actually facilitate or appear to facilitate attempts to inflate, duplicate, or create fraudulent healthcare claims. Recent investigative news reports have suggested that EHR documentation practices have led to inflated Medicare claims. The impact of EHRs on fraud and abuse has also caught the attention of the Department of Health and Human Services Office of Inspector General. The copy and paste function provides the ability to re-use all or parts of detailed narrative information and is seen by physicians and EHR system users as a valuable and time saving tool. This duplication of notes can be conducted within a single patient’s record or across multiple patients’ records. Copying and pasting of healthcare documentation from previous medical record entries is not a new phenomenon and seems extremely common—indeed, prevalent—with at least one study finding that as many as 90 percent of physicians use this functionality in daily progress notes and that a majority of narrative notes contain copied text.

Benefits of documentation assist features (i.e., EHR functionalities that assist with documentation, such as copy/paste) include improved efficiency of data capture, timeliness, legibility, consistency, and completeness. Efficiency of documentation can be increased in a time constrained environment. Judicious use of copy and paste enables the creation of a better clinical note to support communication among care providers. Industry stakeholders such as third party payers have an interest in assuring appropriate documentation for payment and may review claims along with medical record documentation to ensure proper payment. Other stakeholders may review and compare data and documentation for performance and outcomes measures. However, a number of challenges and risks associated with the copy/paste function have been identified. These include:

• Inaccurate or outdated information
• Redundant information, which makes it difficult to identify the current information
• Inability to identify the author or intent of documentation
• Inability to identify when the documentation was first created
• Propagation of false information
• Internally inconsistent progress notes
• Unnecessarily lengthy progress notes

What controls might be put in place related to the copy and paste functionality? How effective could these be?

Electronic health records (EHRs) have been hailed as an enormous step forward in the provision of health care services because they enhance the accuracy, accessibility, efficiency and cost-effectiveness of documentation of services provided. Use of EHRs, however, also raises a number of important issues that may compromise their usefulness. The Office of Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS) recently identified use of the so-called "cut and paste" functionality of EHRs as potentially problematic in terms of possible violations of fraud and abuse prohibitions.

Now AHIMA (American Health Information Management Association); on March 17th 2014 issued guidance called "Appropriate Use of the Copy and Paste Functionality in Electronic Health Records." According to AHIMA, the copy and paste function allows providers to re-use all or parts of detailed narrative information. This duplication of notes can occur within a single patient's record or between multiple patients' records. AHIMA acknowledges that misuse of the cut and paste function may enhance the likelihood of fraud and abuse allegations. AHIMA also points out that misuse of this feature has the potential to result in or contribute to challenges regarding the quality and safety of patient care and the integrity of health records. Specifically, use of the cut and paste feature presents the possibility of the following challenges and risks:

• Inaccurate or outdated information;
• Duplicate information that makes it difficult to identify current information;
• Inability to identify the author of the information;
• Inability to identify the intent of the information;
• Inability to identify when the documentation was first developed;
• Propagation of false information;
• Progress notes that are inconsistent; and
• Progress notes that are unnecessarily lengthy.

AHIMA's position with regard to use of the cut and paste feature is that use of this feature should be permitted only when strong technical and administrative controls have been put in place that include:

• Organizational policies and procedures that govern the use of the cut and paste feature;
• Requirements for participation in user training and education;
• Ongoing monitoring of the use of the cut and paste feature; and
• A process for weighing the benefits in terms of efficiency and time savings against the potential for inaccurate, fraudulent or unwieldy documentation.

One practical step that providers may want to take in order to address the above issues is to link to the original source, rather than duplicating the information using the cut and paste feature. Use of the cut and paste feature clearly needs to be managed consistently and effectively. The healthcare industry is just beginning to consider how best to do so.

What alternatives to the copy and paste functionality are available? What are the pros and cons associated with each option?

Copy and paste functionality can support efficiency during clinical documentation, but may promote inaccurate documentation with risks for patient safety. Many clinicians use the copy and paste functionality provided by operating systems in electronic health records (EHRs) to improve usability by allowing providers to insert text with test results or exam information, maintain stable medication lists, and improve documentation efficiency, particularly when systems lack interoperability. However, copy and paste may also promote longer, poorly organized, and less accurate notes due to inclusion of redundant, outdated, or inconsistent information. In a large physician survey, 25% agreed that copy and paste makes progress notes more likely to lead to a mistake in patient care. Subsequently, professional organizations including the American Health Information Management Association, the Association of Medical Directors of Information Systems, and the Federation of State Medical Boards have formally addressed aspects of copy and paste use in position/guidance statements. Additionally, copy and paste may enable reimbursement fraud, allowing users to easily attest to care they have not provided. Nevertheless, a recent report by the U.S. Office of the Inspector General found that only 24% of organizations had a copy and paste policy in place. The Partnership for Health IT Patient Safety (The Partnership) was formed to gather data, conduct analysis, provide education, and disseminate recommended practices with the goal of enabling safer care using health information technology (IT). The Partnership collectively decided to establish single-topic workgroups addressing particular patient safety issues; the first workgroup was established to address the practice of copy and paste. This workgroup was composed of a diverse group of stakeholders including vendors, providers, representatives from professional organizations, academicians, and safety experts. Although cognizant of the regulatory, legal, and compliance issues
around reimbursement fraud, the workgroup intentionally focused on identifying clinical risks and possible interventions for safe copy and paste functionality to improve patient safety.

To ensure input from key stakeholders, the workgroup reviewed vendor alternatives to copy and paste, examples of practices that promoted safer use of copy and paste, and presentations from several professional organizations and subject matter experts. Workgroup members will be asked to prioritize a list of all potential identified solutions. Using the highest-ranked potential solutions, the workgroup will draft preliminary recommendations, which will be ranked according to feasibility, importance, and impact. Recommendations will be categorized based on means of implementation (e.g., through regulation, technology, education, or policy and procedures) and effect on each stakeholder group (providers, provider organizations, vendors, professional organizations, and patients).