Posted by: adelvecchio
copy and paste, EHR, healthcare fraud, upcoding
Guest post by Charles Settles, content writer, TechnologyAdvice
No medical professional enjoys data entry. One of the most-cited frustrations with electronic medical records software is “double-charting,” or having to enter the same data in multiple places. Copying and pasting EHR data has become the solution for many physicians, albeit a dangerous one. According to a 2013 AHIMA report, as many as 90% percent of physicians use copy and paste in their EHR programs.
After a full day of patient encounters, it’s no surprise that physicians don’t look forward to hours of paperwork. While copy and paste encounter data may save time, it can lead to serious errors, and call a physician’s true intentions into question.
According to a Department of Health and Human Services report, copy and paste functionality can contribute to healthcare fraud. Healthcare fraud, according 2009 figures from the Center for Medicare and Medicaid Services, costs taxpayers and insurers between $75 and $250 billion a year. “Upcoding,” or using increased documentation to justify billing Medicare or insurers at higher rates, can be easily done by copying and pasting previous visit information or a template of generic information to satisfy the increased documentation requirements. A few clicks can generate a pages-long note that’s not only difficult for other physicians to decipher, but for regulators as well.
Fraud may be the primary concern for the government and insurers, but even more troubling is the potential for inaccurate data to be included in a patient’s health record.
Inaccurate data could result in embarrassing yet harmless mistakes — like a male patient being scheduled for a pap smear — or it might have a much more serious and life-threatening outcome, such as an allergic reaction to a medication.
In addition to fraud and patient harm, misuse of copy and paste could result in a patient’s privacy being compromised. Imagine a situation where a physician copies information from one patient file and mistakenly pastes it into another patient file. Of course there’s potential for physical harm to the patient whose file received the inaccurate data, but the patient whose data was mistakenly copied could have information revealed about him that could allow his identity to be compromised or stolen.
Unfortunately, there are few options to combat the misuse of copying and pasting EHR data. Most viable solutions require EHR vendors to modify their software, which many companies hesitate to do. The solutions that don’t require software modification can create almost as many problems as they solve. Increased oversight by supervising physicians could help curb the misuse of copy and paste. Physicians are already required to review nurses’ input; having them read each note and correct inaccurate data instead of rubber-stamping entries would solve the problem of inaccurate data, but would lengthen the time-consuming process of data entry and review. The problem then becomes: who watches the watchers?
The most promising option would be to require programs to highlight copied and pasted information, and link it back to the original entry. Insurers and the government could then easily audit records to discover patterns of fraud due to copy and paste misuse, and supervising physicians could quickly see which physicians (or nurses) were overusing the feature. Disallowing links between separate patient records could prevent one patient’s data from being copied into another patient’s record. Whether or not this solution will come to pass is up to EMR companies and regulatory agencies.