For busy physicians trying to make efficient use of electronic health records (EHR), employing the “copy and paste” feature to transfer information within a patient’s record is a time-saver. Also known as cloning, it’s a common practice among 74 to 90 percent of doctors, according to the American Health Information Management Association.
But instead of being the model of efficiency, the habit is being targeted as a potential cause of medical error and fraud.
Cloning is so pervasive and troubling, it drew the attention of Kathleen Sebelius, secretary of the U.S. Department of Health and Human Services, and Attorney General Eric Holder. They jointly wrote a stern letter to industry medical groups warning physicians to stop copying and pasting information in EHRs. They reported “troubling indications that some providers are using this technology to game the system, possibly to obtain payments to which they are not entitled.”
The HHS Office of the Inspector General also named EHR copy/paste practices as one of its top challenges last year. It noted that cloning could lead to improper payments or inaccurate information in patient records. It’s no small problem.
The Journal of the American Medical Informatics Association reports that 54 percent to 78 percent of physicians’ notes contain copied text.
Many health care leaders bristled at the accusation of fraud, including Rich Umbdenstock, CEO of the American Hospital Association. While cloning and upcoding should not be tolerated, he wrote, “it’s critically important to recognize that more accurate documentation and coding does not necessarily equate with fraud.”
There are multiple ways doctors use cloning, such as copying information from a past office visit and pasting it into the record for the new encounter. The problem—and what generates fraud concerns—is that payers could get billed for a service that was done initially but not during the most recent visit, says Ivy Baer, senior director and regulatory counsel for the Association of American Medical Colleges in Washington, D.C.
“It also can lead to poor quality patient care. You’re not getting an accurate note about what happened during that visit,” Baer says. “We want to look at the note and know what’s going on right then and what the treatment plan is. I don’t want to discount the potential for fraud, but it’s a quality of care issue first and foremost.”
Cloning also can cause doctors to repeat errors in a patient’s file.
Todd Searls, director of Wide River, an IT health care consultancy in Norfolk, Neb., gives an example: One doctor mistakenly notes that a patient has a history of cancer. Even if the doctor quickly corrects the error in a note amendment, it could get repeated by another physician who clones the original history. This practice has all sorts of insurance, billing, treatment, and financial implications, and the doctor could be liable for not taking the patient’s history anew, Searls says.
Doctors who copy/paste could set themselves up for an audit by the Centers for Medicare and Medicaid Services, and they should view Sebelius and Holder’s letter as a warning to clean up their practices, Searls says.
“Most of this really isn’t fraud—maybe they could prove it in about 1 percent of cases. But they want to raise the alarm and get the message out that they are going to dig into this practice.”
To avoid an audit, it mostly comes down to training physicians to stop cloning. Instead, Baer says, doctors should cite references, date included, to previous visits or lab results that are pertinent to the current complaint.
Additionally, EHR vendors should develop features that turn copy/paste material into a different color or font, making it obvious that the information came from a past visit. There also should be a way to tell who wrote which portion of a note, adds Baer.
Health care organizations can work with their EHR vendor to turn off certain functions if they encourage cloning or automatic billing, says Searls. They also should create policies and train physicians on what is appropriate. Finally, have compliance officers review patient records and billing to make sure the billing codes actually reflect patients’ visits, he suggests.
Overall, this can lead to better health care practices. “In the end we really do want a good note and a good health record, and I think that’s what physicians want, too,” Baer says. “They need to appreciate the value of that, and the cloning and copying and pasting is unlikely to get them there.”