EHR regulations, interoperability top patient record concerns
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The use of the copy and paste functions in EHR systems remains controversial. When the EHR medical upcoding scandal broke last fall, some commentators implicated the unchecked use of copy and paste during exams in the deliberate inflation of claims. But the debate over the proper role of copy and paste may not be as one-sided as it initially looked, as one doctor said it can actually benefit care.
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"These are just tools," said Larry Garber, M.D., medical director for informatics at Reliant Medical Group. "The fact is, a knife is a tool that, in the hands of a surgeon, can save lives, but you have to use it carefully. It's the same thing with all these tools in the electronic health record. Whatever tool you use, you have to pay attention to what you're doing and use it wisely."
Garber said he uses the copy and paste functions to highlight previous abnormal findings. When this information is copied into the current record he will flag it, discuss with the patient and update the chart as appropriate. He said it allows him to track improvements or declines in the patient's physical condition or any medication changes. This is particularly useful when it comes to patients with complex needs, such as those with diabetes.
A knife is a tool that, in the hands of a surgeon, can save lives, but you have to use it carefully. It's the same thing with all these tools in the electronic health record.
Larry Garber, M.D.,
medical director for informatics, Reliant Medical Group
He added that the Reliant Medical Group has policies in place to ensure doctors are not inappropriately using copy and paste. Charts are reviewed periodically by supervising physicians to ensure clinicians are not relying too heavily on this technique. The billing and coding department also reviews charts to make sure everything a doctor bills for is supported by the documentation. If supervisors find evidence of inappropriate documentation practices, it will affect the clinician's next salary review and the organization may take other corrective actions.
This kind of policy makes a difference in whether an organization is able to safely and appropriately leverage the copy and paste functionality of EHR systems, said Michelle Dougherty, director of research and development at the American Health Information Management Association. However, while she said there are some circumstances in which copy and paste can be used to benefit care, it can also cause some problems, which is why the controversy won't go away.
The risk of copying outdated and inaccurate information into the current record is the most serious, Dougherty said. When physicians copy a full record from a previous patient encounter, some information is bound to have changed. However, not all doctors are diligent about updating this information. This means that when another clinician reviews the doctor's notes, they could be looking at inaccurate information that does not reflect the patient's condition, which can contribute to potentially unsafe care.
"Those [examples] are unfortunately more common than we'd like to have happen," Dougherty said. "When you're under pressure or behind on documentation, that copy-paste function, left without any rules or checking, becomes a tool that can become a compliance issue."
She said EHR systems should have built-in functionality to help control copy and paste. For example, imported information should be automatically flagged, and pasted notes should be linked back to the original source. Additionally, she would like to see more person-centric dashboard designs in EHRs so physicians can view all the relevant information from past patient visits in one place, rather than require doctors to look back through several documents and copy old information from previous notes.
"They have to use copy and paste to track progress versus having some kind of tool. That's the sort of input that we need EHR systems to be able to do," Dougherty said.
Others have gone farther in their recommendations. In testimony delivered to the Office of the National Coordinator for Health IT in a February Clinical Documentation Hearing, Ivy Baer, senior director of the Regulatory and Policy Group at the Association of American Medical Colleges, said the use of the copy and paste functions raises the risk of using information that is not collected during the encounter for the purposes of billing, which leads to medical upcoding. For this reason, she recommended limiting the use of copy and paste.
But Garber said these kinds of concerns are overblown. Once people understand how the copy and paste functions can be used appropriately, he contended, they will understand it can be a tool for improving patient care. He acknowledged the potential for abuse, but said the potential benefits outweigh the risks.
"It's about educating people on how powerful and useful these tools can be when used appropriately," Garber said. "I think the check and balance is a great idea to make sure these tools are not abused."