Electronic medical records require a lot of interaction on the part of physicians and other providers to get all necessary information entered. There are drop down menus, boxes to check, and other information to fill in. With the well documented complaints about impact on workflow, a number of workarounds have been mentioned for a long time. Foremost among the workarounds is the use of copy and paste. Copy and paste can come in many forms including taking the entire contents of one note and bringing it forward, using templates to fill in predetermined information based upon a set of standards, or other similar uses. The premise is to make use of the EMR easier and more user-friendly. However, like most actions within healthcare, there are risks.
Let’s explore the benefits and arguably permissible uses of copy and paste first. On the positive side, copying and pasting through the use of templates lets providers input a baseline of information, such as all normal results in a systems check. For example, a fact sheet produced by the Centers for Medicare and Medicaid Services suggests that templates or auto-fill can improve physician documentation and lead to more complete information being included in the medical record. An appropriately utilized template can potentially prompt the physician to include relevant information from a patient examination, which in turn ensures a fuller picture of the patient is present for future visits. Such positives can be achieved through careful, considerate and deliberate use of templates.
While the positives suggest the ability to enhance patient care, there are also numerous negatives. For example, the Office of the Inspector General has made its position well-known that copy and paste functionality can lead to fraud and abuse. The argument is that copying and pasting from one note to another can result in additional information being included resulting in claims being coded at a higher than justified level. The argument rests upon an assumption that information not actually collected or services not rendered would be included and billed. Such an assumption to some degree assumes guilt as opposed to innocence in provider activities. Such usage would more accurately be described as cloning and could lead to complications. Trying to be optimistic, hopefully the majority of providers are not using copy and paste functionality with an intent to defraud a governmental or private payor.
Another less obvious drawback from copy and paste is the creation of confusion within a medical record. If information is continuously carried forward, it may be difficult to determine when the information was first collected and whether the information is still accurate. Such a scenario could arise where copy and paste is used, but then not modified to reflect a patient’s current status or if it is used to build upon prior information in a repeating and lengthening record. Either way, the muddying of the medical record could give rise to potential liability in the event of an adverse patient outcome. For example, the confusing medical record could make it difficult to demonstrate that a standard of care was met or be the root cause for a bad outcome.
Both scenarios are not ones that a physician or other provider would want to discover in the context of litigation.
Much more could be said about the benefits and dangers of copy and paste. Many will and likely do use the functionality. The key is to be considerate in such usage and not use it as an excuse to be complacent.
Matt Fisher, Esq. is the chair of Mirick O'Connell's Health Law Group and a partner in the firm's Business Group. Follow him on Twitter: @matt_r_fisher. He is also the host of Healthcare de Jure which airs on HealthcareNOW Radio. This article was originally published on Mirick O’Connell’s Health Law Blog.