Cutting and pasting functions in the EMR and EHR can damage the integrity of the medical record.
The practice of cloned or copied-and-pasted documentation is a significant issue in the use of electronic health records (EHRs).
A recent study in the Journal of the American Medical Association (JAMA) found that of hundreds of progress notes examined by researchers, just 18 percent were newly entered by clinicians (Wang, 2017).
The Centers for Medicare & Medicaid Services (CMS) defines cloned documentation as “multiple entries in a patient’s health record that are exactly alike or similar to other entries in the same patient’s health record or another patient’s health record.” (CMS, n.d.) Terms used for duplicative documentation also include copy forward, macros, and save notes as a template. Let me explain some distinctions:
- Cloned Documentation: Medical record documentation that has been cut and pasted from another source location, which may or may not accurately reflect information specific to the current patient encounter.
- Copying and Pasting: Selecting data from an original source or previous source to reproduce at another location.
- Cutting and Pasting: Removing or deleting the original source text or data to place in another location. Cutting and pasting should never be allowed, as it alters the original source material.
- Copy Forward: A function that copies a significant section of a prior note.
- Template: A documentation tool that features predefined text and text options used to document a patient visit within a note.
- Populating by Default: Data that is entered into a note via an electronic feature that does not require positive action or selection by the author.
There are several issues with “cloned noting” that can be a red flag for a potential audit in your clinics and offices as well.
First, inappropriate use of cloned documentation can damage the trustworthiness and integrity of the record for patient care. There are also reimbursement implications of cloned documentation that lacks patient-specific information necessary to support medical necessity requirements for services rendered to an individual patient.
The U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) issued the following statement in 2013, concerned with copying and pasting practices:
“Copy-pasting, also known as cloning, allows users to select information from one source and replicate it in another location. When doctors, nurses, or other clinicians copy-paste information but fail to update it or ensure accuracy, inaccurate information may enter the patient’s medical record and inappropriate charges may be billed to patients and third-party healthcare payers. Furthermore, inappropriate copy-pasting could facilitate attempts to inflate claims and duplicate or create fraudulent claims.
Over-documentation is the practice of inserting false or irrelevant documentation to create the appearance of support for billing a higher-level of service. Some EMR/EHR (electronic medical record/health record) technologies auto-populate fields when using templates built into their system. Other systems generate extensive documentation on the basis of a single click of a checkbox, which if not appropriately edited by the provider, may be inaccurate. Such features can produce information suggesting the practitioner performed more comprehensive services than were actually rendered.
Since the beginning of EHR/EMR implementation, many reputable sources have weighed in on the risks associated with copying and pasting. The American Health Information Management Association (AHIMA), as well as several Medicare Administrative Contractors (MACs), such as Noridian, FCS Options, and Palmetto, have voiced their opinions loudly.
Noridian Healthcare Solutions, LLC (the biggest MAC payor in the U.S.) created local coverage determination (LCD) guidance on using EHR templates when documenting a patient encounter, specifying that “documentation to support services rendered needs to be patient-specific and date-of-service-specific. These auto-populated paragraphs provide useful information such as the etiology, standards of practice, and general goals of a particular diagnosis. However, they are generalizations and do not support medical necessary information that correlates to the management of a particular patient. Part B medical records are seeing the same auto-populated paragraphs in the HPIs of different patients. Credit cannot be granted for information that is not patient-specific and date-of-service-specific.”
The integrity of the health record should be protected at all costs. Listen in to Talk Ten Tuesdays and my segment on cloned noting today, Tuesday, July 2, for recommendations on how to incorporate policies and procedures to protect your records.
It is never too late to be proactive with continued implementation of EHRs, which continue to carry the risk of misuse of copy-and-paste functionality. We are here to provide guidance on this issue and make sure you are a complaint in your practices, ensuring the integrity of documentation of patient care.
Listen to Terry Fletcher report this story live today on Talk Ten Tuesday, 10-10:30 a.m. EST.