Simple EHR Function May Trigger Audits, Hospitalist Cautions

Cheryl Clark, August 7, 2014

Hospitals should adopt policies to encourage the appropriate use of the copy and paste function in electronic medical records systems because Recovery Audit Contractors who find similarities among patient records may use them as a basis to deny claims, says a physician.

Clinicians' use of the "copy and paste" function in electronic health record systems may soon be the subject of indiscriminate Recovery Audit Contractor reviews, a prominent hospitalist warns.

"We're worried that we're going to be audited based on good use of copy and paste, and that we're going to be prohibited from using copy and paste for the things that it really is good for," says Ann Sheehy, MD, a member of the Society for Hospital Medicine's Public Policy committee.

For example, she says, the Centers for Medicare & Medicaid Services has hinted that it may allow auditors to use linguistic tools that look for similarity in patient records text, much like academicians or editors may look for plagiarism, and use their findings as a basis to deny claims.

"They might be able to just look at the pure sameness of the text. For example, they might say, 'Dr. Sheehy, your notes are 75% the same as they were yesterday,' or 'they're 75% the same as this other patient,' when actually, I looked at everything and validated everything, [and] actually, the same thing was what happened both times."


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