Our health care system’s slow-but-sure conversion from paper to electronic health records (EHR) continues throughout the United States. The push toward EHR is strong, both as an inevitable industry trend toward efficiency and because of the mandate of federal law. EHR is obviously an integral part of health care reform changes. See January 31, 2013 post. Unintended adverse consequences of going paperless have appeared, however, including an apparent trend by doctors and other health care providers to haphazardly copy and paste identical notes from one patient visit to another.
This phenomenon — dubbed “sloppy and paste,” “sloppy pasting,” “copy-forward” and “cloning” — is a new problem in the industry and appears to be a strong trend. Although EHRs facilitate quick moves through patient records, the tempting ease of copy/pasting lends itself to mistakes. While many such mistakes may be innocuous, as an expansive trend copy/pasting EHR seems to have some meaningful unintended consequences, ranging from serious embarrassment, the appearance of billing fraud, or patient harm.
For example, since by definition coordinated patient care (another integral part of health care reform for which there is strong impetus) involves multiple health care professionals communicating with each other via the patient’s chart, the ability of each provider to rely upon the accuracy of information conveyed in the chart is critical. Proper management of all patient care in an integrated way requires an effective, accurate and timely exchange of information. The reliance of each provider upon inaccurate or misleading information copy/pasted into chart as a short cut can lead to confusion and mistakes and actually prevent “coordinated” care. In one reported example, a physician visited a patient in a coma who had postoperative complications. After reviewing the patient’s chart, the doctor visited with the patient’s very concerned family and commented to them that the patient was only in the third day of recovery, unaware that that the patient had been in recovery for over five weeks. For more than five weeks, the note “post-op day No. 2” was copied and brought forward each day. The highly embarrassed doctor’s credibility with the family was gone.
Though the practice and effects of copy/pasting may vary among different health care delivery settings, research confirms that copy/pasting EHR is indeed very widespread. Critical Care Medicine featured in its February 2013 issue a study of the prevalence of copied information by attending physicians and resident doctors in ICU notes. In that study, which utilized software that identifies matching word sequences, 2600 pages of progress notes regarding 135 patients created by 11 attending physicians and 62 residents over a three month period were surveyed by experts. That study determined that 82% of all residents’ notes and 74% of all attending physician notes contained not less than 20% copied information.
Nevertheless, many physicians correctly maintain that eliminating the utility of copy/paste would render record keeping more time consuming and costly. To minimize legal risks and other potential problems caused by copy/pasting EHR, health care providers should take appropriate steps. The Georgia Access Management Association offers guidelines for copy/pasting EHR: use great care in copy/forwarding information in EHR, provide attribution to another provider’s notes, avoid repetitive copy/pasting of laboratory notes and radiology reports, observe and indicate the proper context of all notes, and limit information that is not truly necessary.
Another essential step is to consult with a billing and coding pro with training and experience that can save a medical practice substantial trouble and expense. For example, Steve Adams is a highly regarded expert in medical coding and documentation, who assists physicians and other health care providers in their efforts to obtain all legitimate reimbursement without costly mistakes.
Kevin Little is a Georgia and South Carolina business and health care lawyer who represents doctors, physician groups, ambulance service providers, nursing homes and other health care providers and health care businesses. Our law firm can be reached at (404) 685-1662 (Atlanta) or (706) 722-7886 (Augusta).
*Disclaimer: Thoughts shared here do not constitute legal advice.