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Be wary of copy-and-paste EHR mistakes

November 11, 2014
by Julia Brown
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Copy and paste functionality in electronic health records (EHRs) can be beneficial for providers, shaving time off the sometimes tedious process of updating notes and patient encounters. However, the practice of pasting in EHR information also comes with some potential risks for fraud and treatment errors from tainted records.

“There’s a world of efficiency that cut and paste brings,” says Lisa Pierce Reisz, partner, Vorys, Sater, Seymour and Pease LLP, a Columbus-based law firm. “Talk to any provider and the bane of their existence—like all of us—is documentation. Today, it feels like there continues to be more and more requirements for documentation by numerous regulators. It solves that issue.”

However, if providers are not diligent in reviewing the information that often is quickly pasted in, the feature can be a vehicle for introducing errors that could result in fraud charges and possible fines for upcoding, for example. Accidentally paste in the wrong code without looking closely, and false claims could be submitted unintentionally for services that were never provided.

“It runs the gamut from a simple mistake that could be painful to pay back, to something more systematic, to false claims and even criminal penalties for fraud,” Reisz says.

Inputting incorrect information from the wrong patient encounter could not only negatively affect future care delivery, but it could also result in dangerous prescription errors.

“From the outside looking in, there seems to be more risk than benefit,” says Robin Canowitz, senior attorney at Vorys, Sater, Seymour and Pease LLP. She says providers must edit each time they’re updating a patient’s medical record to ensure that the information being recorded is accurate, up to date and aligns with the patient services they’re providing.  

“You’re trying to ensure your documentation integrity,” Reisz says. “There really is no difference in concept from paper records, just more opportunities for mistakes, for those sorts of nuances to be lost, and it really taints the record.”

How to manage copy and paste

Although the cons certainly outweigh the pros, opting to turn off the functionality isn’t necessarily the answer either. Instead, Reisz says, the solution lies in provider training on the front end and monitoring and auditing on the back end.

She says providers should maintain what they have most likely been doing already from a documentation standpoint—making sure that records are complete and accurate. Training upfront allows providers to fully understand the risks of using the functionality, and a good audit and monitoring program ensures that the training concepts stick.

“The best way to learn is through examples that really occurred,” Canowitz says. “As people are auditing, if they find [errors], use those in further training sessions to show what the dangers are, what the risks are. Those real-life examples in a training setting are really important to make people understand that even though they cut, copy and paste, they need to read it and edit it and make sure it’s accurate as of that moment.”

Additionally, establishing a policy that outlines expectations for when providers use the functionality also might be beneficial for eliminating potential errors. For example, limiting the copying and pasting to progress notes of the same patient, limiting to objective data such as lab information and vital signs, and attributing what was copied to an original source can all help to reduce errors.

“Plans of care should be changed daily based upon what is happening with the patient. When they cut and paste the plan from the last visit? That’s where they can get into trouble,” Canowitz says. “The plans of care are usually considered subjective data.” 

Regardless of the copy-and-paste policy, mistakes are going to happen even with the most sophisticated EHR system. Consider outlining a strategy to reduce mistakes and prevent future errors.

“If you have systems, processes, and written policies and procedures in place that are meaningful, that can go a long way and lessen some of the back-end problems,” Reisz says. “It really is taking what was good paper documentation and compliance and transitioning that to the electronic age and really understanding the risks, ensuring that you’re taking every step in making sure your documentation integrity is intact, and that mistakes are minimized.”

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