Double Jeopardy

Vol. 20 • Issue 4 • Page 14

Medicine’s most dangerous tool could be the right-click. The infamous copy-and-paste shortcut is beloved by students and professionals alike, but when the text contains patient data, users are piling on risks.

Attack of the Clones

Copy-and-paste has long been a function in word processing, but it’s taken off in the era of EHRs. Physicians tired of typing the same notes day after day can simply drop in documentation for a normal exam or common procedure; for a particular patient, family history or medication lists can be copied from a previous caregiver. EHRs can even auto-populate data by “pulling forward” data or using templates the physician and IT staff create during implementation. Copying saves time and frustration, but the focus on speed could prompt users to miss errors.

“We’ve seen whole physical exams copied and pasted from days ago, which is clearly false data. We’ve seen wrong vitals copied and pasted, so people may be acting on vital signs that may be 24-48 hours old,” said Sarah Augustine, MD, associate chief of medicine at Louis Stokes Cleveland VA Medical Center.

Copy-and-paste is particularly risky when a doctor copies records from another physician, according to Diana Warner, MS, RHIA, CHPS, professional practice resources manager for the American Health Information Management Association. “Typically, when they do it, it is on the same patient. but in some specialties where patients have similar diagnoses, they may just copy it from Patient A to Patient B,” she said.

Problems arise when the original physician notes an error; the original document will be amended, but the cloned data won’t reflect that change, Warner explained. Such disparate data could wreak havoc on patient care and the legal health record.

Those are cases of direct harm to the patient, but copied data can also cause indirect complications. Notes that are pasted over and over become redundant, and providers have little time or patience to sift through the material. “There is no narrative quality left to the note,” Dr. Augustine said.

Coding professionals typically don’t copy-and-paste, but the shortcut affects them down the line. Improper copying can lead to fraudulent billing, warned Rhonda Buckholtz, CPC, CPC-I, CGSC, COBGC, CEPDC, CENTC, vice president of business and member development for the American Academy of Professional Coders. For example, doctors may only examine a specific part of the body, but will paste documentation for a complete physical exam. Unaware of the copy-and-paste error, coders bill according to the documentation-until auditors flag the facility for upcoding.

Other downstream problems range from privacy and security issues when personal health information winds up in the wrong chart, to legal health record concerns regarding what has or hasn’t been done during the patient’s stay.

Duplicitous Documents

It’s hard to tell when data has been copied and pasted, according to the experts. EHR systems don’t distinguish cloned data from original notes, and because HIM professionals cover several physicians’ cases, they won’t pick up on copy-and-paste abuse. The only glaring indicator, according to Dr. Augustine, is when physicians copy the previous caregiver’s electronic signature, so two signatures wind up at the bottom of the page. That in itself can cause major legal issues. “I would not want my signature block copied and pasted,” she said. “You never know what the other author’s putting in their notes.”

Auditors, however, look at several cases at once, so they’re more apt to notice canned documentation. “I can tell you just by looking at a handful of records how much time and effort has been put into those templates,” Buckholtz said. Fault falls to the physician, but fraud allegations will nonetheless affect the coding team and facility’s reputation.

The tricky part about copy-and-paste is that some caregivers might not realize they’re doing it. In some cases, providers actively highlight, select “copy” and then paste data into their notes, but the pull forward method in many current EHR systems does that automatically. It’s a time-saver, but a gamble-especially when providers are unfamiliar with the feature. “If you don’t have someone guarding that information and making sure it’s updated, it can cause a lot of problems for the physician,” Buckholtz said.

Among the issues, she explained, providers could be working with 3-month-old lab results as if they were current data.

Erasing Risks

Despite its fallbacks, copy-and-paste can be an effective tool-when used properly. “It’s not copy-and-paste; it’s copy, paste and edit,” Dr. Augustine summarized.

Facilities should define specific policies for use of copy-and-paste functions, such as requiring physicians to review copied notes to ensure that inaccurate or irrelevant details have been deleted. Implementing those policies will require some education, and that’s where coders should get involved. “They can tell you what needs to be in [the record] and how documentation should flow,” said Buckholtz, who called education “the biggest piece” of avoiding copy-and-paste abuse.

HIM professionals can also keep tabs on compliance, Warner said, and the more eyes, the better. “Your internal coders, auditors, anyone that’s looking at records, reviewers, even the quality assurance people who are looking for outcomes, sometimes they do notice those patterns,” she said.

When addressing pull forward use, the HIM department should work with IT staff to define parameters before the function is activated, Dr. Augustine advised. Data should be limited to a 24- or 48-hour window, so providers can be confident that information is up-to-date.

The experts also encouraged facilities to explore alternatives. Physicians should aim to be more concise in documentation, Dr. Augustine said-typing a brief note is faster than copying a lengthy one. Some EHR systems also offer citing, Warner said, which drops in current data from an updated source, such as a medication list that’s frequently reviewed by staff. The function also usually notes when details have been cited, so there’s no confusion over who wrote what.

As more hospitals and physicians adopt EHRs, the risks of copy-and-paste will only increase. How to keep risk from becoming reality? “That’s the million dollar question,” Dr. Augustine said.

Cheryl McEvoy is an assistant editor with ADVANCE.