Answer Happy

Search for supporting document from the AHIMA, CMS, Public
Health websites, etc. Summarize your findings in your own
words pertaining to cloning and pasting in the medical
record.
Is It Possible to Curtail Copy and Paste?
By Lisa A. Eramo, MA
For The Record
Vol. 29 No. 10 P. 18
The theory goes that the emergence of best practices and
value-based reimbursement will discourage the practice.
For years, health care experts and professional associations
have warned providers of the dangers of copy-and-paste
documentation within the EHR. Yet HIM professionals and others
continue to talk about it, voice frustration, and reluctantly deal
with the consequences of using it (eg, bloated documentation,
inaccurate code assignments, patient safety risks, and more).
Might the conversation evolve as best practice strategies begin
to emerge? What can organizations do to adapt documentation
practices, and will the shift toward value-based reimbursement help
steer the industry in the right direction?
Prevalence of Copy and Paste
As organizations have implemented EHRs, rates of copy-and-paste
documentation have remained high, according to a special report
published by the ECRI Institute that recently evaluated 13 studies
examining the frequency of copy and paste.
Though the studies don't distinguish between appropriate and
inappropriate use of copy and paste, it's obvious that the
functionality causes problems for hospitals and physician practices
alike, says Lorraine Possanza, DPM, JD, MBE, director of the ECRI
Institute's Partnership for Health IT Patient Safety.
Jon Elion, MD, FACC, president and CEO of ChartWise Medical
Systems, agrees. "We're drowning in data and thirsty for
knowledge," he says. "It's very easy when you write a note to
automatically include lab data, medications, problem lists,
allergies—and you've generated a note that's five pages long before
you've written one word."
Cynthia Nicholas, MSA, RHIA, CPHQ, CHC, vice president of
coding, audit, and compliance at Atos Digital Health Solutions,
says problems with copy and paste seem to be at an all-time high,
with much of the problem driven by medical necessity. Once
physicians identify the buzzwords payers require as a prerequisite
for payment, they tend to use that language repeatedly without
tailoring it to each patient's unique clinical presentation,
Nicholas says. In fact, a high percentage of unrecoverable medical
necessity denials may be the first sign that an organization has a
problem with copy and paste, she notes.
An adverse event such as a medication error in which a patient
receives the wrong medicine or the wrong dosage due to inaccurate
documentation is another sign of potential copy-and-paste issues,
says Ann Meehan, RHIA, director of information governance at AHIMA.
Without these clues, organizations could struggle for years with
inappropriate use of copy and paste without even knowing it, she
says.
An inability to monitor the use of copy and paste continues to
perpetuate the problem in many organizations, says Meehan, who
previously worked as the vice president of HIM at a large
integrated health care delivery system. During her time there,
internal IT professionals tried to develop reports that would query
individual records to identify repeated text phrases. Meehan says
the reports, many of which were hundreds of pages long, required
manual review and often led to false positives. Without vendor
support, trying to monitor the use of copy and paste was virtually
impossible, she adds.
Challenges Abound
Although copy-and-paste documentation may increase efficiency for
physicians, it tends to do just the opposite for coders,
abstractors, auditors, clinical documentation improvement (CDI)
specialists, release of information specialists, and payers.
For coders, the challenge is the overwhelming amount of
documentation that must be reviewed, Nicholas says. Coders must
wade through everything—even when it's obvious that the
documentation has been cloned—because there could be one line or
phrase that's unique to the patient that could affect code
assignment. Besides being onerous, this process puts coders in the
difficult position of having to scour information and/or query
physicians, Nicholas says.
It's also difficult for vendors and managers to set productivity
standards when they know records with cloned information take
longer to review. Nicholas says there could be as much as a 20%
decrease in coder productivity for a complicated inpatient case
when a significant amount of documentation has been copied and
pasted.
She frequently sees cases for which admitting physicians pull
the entire emergency department (ED) record into the patient's
history and physical. Specialists subsequently continue to pull
this information forward throughout the record, including into the
discharge summary. "You end up with a 99-page discharge summary
because all they've done is copy and paste everything from the
entire stay into one document instead of trying to summarize and be
more specific," Nicholas says.
This not only affects coders but it also makes physicians
particularly vulnerable during malpractice lawsuits when attorneys
could feasibly find critical clinical information buried within the
documentation that a physician overlooked because he or she copied
and pasted the information without ever reading or validating
it.
In its special report, the ECRI Institute highlights several
particularly egregious examples of how copy and paste posed real
risks to patient safety. For example, a patient who presented to
the ED with atrial fibrillation and potential heart disease was
discharged to his primary care physician. The physician failed to
diagnose cardiac disease and instead copied the same assessment and
plan over 12 office visits during the next two years. The patient
died from a heart attack, and the physician was successfully
sued.
Another example involved an infant for whom the initial EHR note
specified no history of tuberculosis (TB) exposure despite recent
travel to a TB-endemic country. Subsequent office visit notes
included copy-and-paste documentation related to the negative
exposure to TB until two weeks later when the child was diagnosed
in the ED with TB meningitis, leading to significant residual
deficits.
Other consequences may be less clinically severe but
nevertheless cause significant inconveniences for patients. For
example, consider a patient who reports a family history of cancer.
When this information is incorrectly listed under the patient's
past medical history—and subsequently copied forward without
validation—a life insurance company could accuse the patient of
deliberately withholding information about a preexisting
condition.
Meehan says there's also the issue of HIPAA violations that
could occur when physicians copy sensitive personal or clinical
information from one patient's record into another—and then that
information is released.
Other consequences may not affect patients directly but could
raise a red flag with payers, she says. For example, when payers
see the exact same vital signs and physician observations over the
course of several days or a week, this could prompt a closer
examination of documentation that could lead to denials.
Deborah Grider, CDIP, CCS-P, CPC, CPC-I, CPC-P, COC, CPMA, CEMC,
senior health care consultant at KarenZupko & Associates, says
payers know that copy-and-paste documentation can artificially
inflate evaluation and management levels, which is why they're
beginning to request records for multiple dates of service to
determine whether the review of systems, for example, is exactly
the same.
"If you didn't really do the work, then you've submitted a false
claim," she says, adding that she recently audited a hospital-based
physician who had to repay millions of dollars to a Medicare
contractor because of cloned documentation over three years that
made the payer question whether he actually performed the work.