EXECUTIVE SUMMARY

Physicians can create compliance risks by overusing copy-and-paste in electronic medical records. The records can result in upcoding and the loss of reimbursement.

  • Some use of copy-and-paste is legitimate.
  • Repeating notes for different patients is dangerous.
  • Records can become so confusing as to be unusable.

Overuse of copy-and-paste in medical records poses risks to patient safety and quality of care, but it also is a compliance risk.

It can be appropriate to copy and paste in an electronic medical record (EMR), but physicians can overuse it, says Janice Jacobs, CPA, CPC, CCS, CPCO, ROCC, managing director with Berkeley Research Group in Washington, DC. They can legitimately use it to save time and not have to retype information that is not specific to a particular date of service, information such as patient demographics that remain static from one encounter to the next.

“Unfortunately, everyone has gotten on the copy-and-paste bandwagon and they’re using it for way too much information,” Jacobs says. “The risk is that they are carrying forward old and outdated information. If they’re cutting and pasting information, they may be carrying forward information that is outdated or just not relevant to the current encounter being documented, particularly if the patient has a new complaint and this is not a continuation of the treatment from the previous encounter.”

That can lead to coding and other compliance risks, Jacobs says.

“Perhaps on the earlier visit, a lot more work was done that required a certain amount of reimbursement, but this visit was minimal in comparison and the reimbursement should be much less,” she explains. “Copying and pasting lots of information runs the risk of upcoding, and also the risk of creating a medical record that is so loaded with text and repeated information that it is almost impossible to tell what happened and when. That could result in upcoding but also downcoding, where you leave money on the table just because no one can tell what really happened with any certainty.”

Accidentally Copying Wrong Text

The physician also may inadvertently copy and paste information from another clinician, which then becomes part of the current physician’s account of care, muddying the timeline and responsibility for the patient, she says. It also is possible for physicians to copy information from one patient’s record to another patient’s.

“I have audited records where the physician had the exact same note, word for word, in 25 patient medical records. Obviously, there was nothing customized to that particular patient, so if someone else comes in and tries to assume care for that patient, they are depending on a note that was the same for 25 patients, which means it may not tell them key information about this one particular patient,” Jacobs says.

CMS is aware of this risk and looks for evidence of extensive copied text, Jacobs says.

“They will look for records that look identical, and there is the potential for having money taken back if they see no change from one note to the next,” Jacobs says. “They are very much aware of this problem.”

Study Finds Heavy Copying

The prevalence of copied text was hard to define until recently, when new software allowed Michael D. Wang, MD, a physician in the Department of Medicine at the University of California, San Francisco (UCSF), to distinguish manually modified text from automatically updated imported values in electronic note templates. Wang and his colleagues studied records from an inpatient electronic record at UCSF Medical Center. They analyzed 23,630 inpatient progress notes written by 460 clinicians, including direct care hospitalists, residents, and medical students on a general medicine service over an eight-month period. (An abstract of the report is available online at: http://bit.ly/2wqepeJ.)

They found that 18% of the text was manually entered, 46% copied, and 36% imported. Residents manually entered less (11.8% of the text) and copied more (51.4%) than did medical students (16.2% of the text manually entered and 49% copied) or direct care hospitalists (14.1% of the text manually entered and 47.9% copied).

With less than one-fifth of note content manually entered, Wang says the results cast doubt on the validity of many electronic records.

Prohibiting copy-and-paste would be a drastic solution, as it can be a timesaver when used judiciously, Jacobs says.

“Education and training with real examples is the best solution, along with internal auditing and monitoring,” Jacobs says. “The compliance should be specifically looking for evidence of this problem, and when found, take it back to the physician and show them real-life examples from their own patients. Show them how the record has the same note for every single date of service, and if you’re audited you’re going to have to give this money back. That usually gets their attention.”

SOURCES

  • Janice Jacobs, CPA, CPC, CCS, CPCO, ROCC, Managing Director, Berkeley Research Group, Washington, DC. Phone: (404) 285-3300.
  • Michael D. Wang, MD, Department of Medicine, University of California, San Francisco. Email: michael.wang4@ucsf.edu.