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Simple EHR Function May Trigger Audits, Hospitalist Cautions

 |  By cclark@healthleadersmedia.com  
   August 07, 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."

In fact, hospitalists frequently use 'smart phrases' to make remarks that are consistent from patient to patient, Sheehy says.

"We don't want auditors to come in and not allow us to use these efficient, good standardization aspects of copy and paste, especially if they use this blunt tool, the percentage of sameness across notes."

Sheehy, who is chief of the Division of Hospital Medicine at the University of Wisconsin School of Medicine and Public Health, says that hospitals should take heed to adopt their own copy and paste policies to encourage appropriate, efficient use of copy and paste, but to discourage fraud and avoid error.

For example, a new policy at her hospital states that "physicians are legally responsible for the content of their notes," and the hospital prohibits billing off of any text inserted by a medical student.

She notes that federal officials have suggested that they will be looking for fraudulent copy and paste practices such as instances in which documentation prepared for one patient is inserted into the record of another, perhaps in an effort to justify a higher billing code.

OIG Reports on 'Cloning' in Electronic records
Most recently, two evaluations and inspections reports from the Office of Inspector General have indicated federal concerns about the use of copy and paste, which is also called "cloning."

In its January report, the OIG said CMS should provide guidance to its contractors on detecting fraud associated with EHRs, and should also identify best practices and tools with which to document it.

The report says that "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."

A month earlier, a separate OIG report noted that only about one-fourth of hospitals had policies regarding the use of the copy-paste feature in EHR systems, which if used improperly, could pose a fraud vulnerability. That report recommended that the Office of National Coordinator and CMS "develop guidance on the use of the copy-paste feature in EHR technology."

Additionally, in September of 2012, then HHS Secretary Kathleen Sebelius and Attorney General Eric Holder, Jr. said in a letter to hospital groups that they found "troubling indications that some providers are using (EHR) technology to game the system, possibly to obtain payments to which they are not entitled.

"False documentation of care is not just bad care; it's illegal. These indications include potential 'cloning' of medical records in order to inflate what providers get paid. There are also reports that some hospitals may be using EHRs to facilitate 'upcoding' of the intensity of care or severity of patients' condition as a means to profit with no commensurate improvement in the quality of care."


MU Fraud on the Rise, OIG Warns


Finally, they wrote, "a patient's care information must be verified individually to ensure accuracy: it cannot be cut and pasted from a different record of the patient, which risks medical errors as well as overpayments."

Not Foolproof
"I'm sure that other hospitals like ours have acted on the government's indications that they're going to start looking at this more carefully, and that this needs to be a priority for all of us," Sheehy says.

Sheehy says that she knows copy and paste can be problematic. For example, she related one "horrible example" in which the record of a patient indicating her husband lived at home with her, was copied and pasted forward, "when in fact the husband had passed away.

"You can imagine this promoted really sad and awkward conversations, and created some [inaccurate] assumptions about what kind of help that patient had at home. Every person who went into the room asked about her husband, and she had to remind them each time that her husband had passed away."

Sheehy wrote in an opinion piece published in the August issue of JAMA Internal Medicine, that improper use of copy and paste can result in poor quality of care.

But she emphasizes that hospitalists and other acute care providers are not saying that their EHR documentation practices should not be monitored by the federal government and its contractors.

"We know there is fraud and abuse out there, and it's CMS' role to look for that. But what we want is auditing that's fair, [and] based on the content and intent of the notes, not just a look at an automated boilerplate that doesn't get to the meat of whether it's a good copy paste or not."

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