Healthcare // Electronic Health Records
09:06 AM

Feds Barking Up Wrong Tree On EHR Fraud?

Most doctors copy and paste to save time, not overbill. But the practice can result in dangerous errors, says consultant.

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Doctors' habit of copying and pasting notes in their EHRs has come under increasing fire from those who suspect that they're using this method to justify higher charges to Medicare and private payers. In October 2012, the HHS Office of Inspector General (OIG) launched an investigation into this practice, and OIG recently issued a report that said the Centers for Medicare and Medicaid Services (CMS) wasn't providing sufficient guidance to its contractors to detect this kind of fraud. CMS promised to redouble its efforts.

Some healthcare consultants believe that the government's crusade is misguided and that efforts to train physicians to use EHRs more effectively would be more valuable. For example, Heather Haugen, managing director of the Breakaway Group, a Xerox subsidiary, told us that most physicians who copy and paste notes do so to increase their efficiency, not to commit fraud.

"I strongly believe they do it to save time," she said. "As we go in and watch their workflows, we see that. Physicians worry about productivity, and many EHR users are uncomfortable with the workflow and with best practices. So they're trying to save themselves some time."

Haugen didn't deny that average charges for some types of visits have risen in the wake of doctors' EHR adoption. But that probably reflects physicians' increased confidence that they have the documentation to justify those charges, she said. In the past, they might have undercoded because they thought their handwritten notes were too sketchy to withstand an audit.

[Despite complaints, the adoption of electronic health records continues to rise. Read Physician EHR Adoption Leaps 21% In 2013.]

Doctors often copy and paste earlier notes into current notes when they don't have time to enter all the data, she said. In many cases, she observed, they do that because they weren't properly trained on the EHR. "A lot of times, they're sort of thrown in there and expected to figure it out."

There's also a lot of resistance among physicians to using point-and-click dropdown boxes to enter all of the data when they're rushing from one exam room to another and trying to get everything documented during visits. Copying and pasting can look like an attractive alternative.

Unfortunately, she said, sometimes the doctors who do this don't properly edit the portions of the earlier notes they've pulled into the current ones. When that happens, patient care might suffer. "Copying notes can be dangerous, and you have to be aware that patient information can be pulled over wrong. I've seen notes with the wrong blood pressures because of copy and paste.

"Copy and paste is a workaround, and I'm not sure a workaround is the best way for us to move forward. You risk a lot of things happening, including being accused of fraud and having errors introduced into the medical record. Then somebody sees that mistake in the record and makes a decision on it later."

Haugen recommends that doctors take the time to customize EHR templates to their preferences or to the way their practice has agreed to document visits. "You want the template that says, 'Here are the five things you need to document.' It's an investment upfront. It also takes a little more work to use a template than to use a previous note, but you're a lot less likely to make a mistake."

The key is to convince physicians that the extra documentation work can help them improve the quality of care, she said. Unless their findings are documented in discrete data, there's no way to measure the care they're providing. Then, when the practice tries to run a report -- to the limited extent that current EHRs allow -- it will generate inaccurate data that can't be used for quality improvement.

"If you start explaining that to a very analytical physician, they'll say, 'Now I understand how you're going to use the information.'" But more often, trainers just tell doctors, here are the check boxes and here's what you have to check. For most doctors, that's just senseless, and it seems like a lot more work."

Another benefit of using templates rather than copying and pasting, she said, is that it reduces over-documentation that makes notes hard to read. "Copy and paste results in notes that are longer than they have to be."

Ken Terry is a freelance healthcare writer specializing in health IT. A former technology editor of Medical Economics Magazine, he also is the author of the book Rx For Healthcare Reform.

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User Rank: Moderator
1/28/2014 | 12:05:38 PM
Re: What's the alternative?
Totally agree having been a former developer of an EMR in the early days, taking a production tool away iss nonsense, and you only get that kind of knowledge spending a couple years with my beta doctor working hard to create a solution for "them"..something I think many forget, you are building a tool for the doctors and not creating for your own hat...

I really had to laugh when I saw all of this come out with restricting copy and paste, it's like trying to control what you can copy and paste into a world document but that's the thinking you get when you have non tech folks trying to solve such an issue..insanity:)  I used to have some very heated session with those doctors too as they wanted the screens and functionality one way and due to privacy or just restrictions I could not do it "exactly" the way they wanted.  Too bad the internet pushes this Burger King perception out there to the public in telling them they can have it their's a joke and a bit media soap opera articles that draw attention.  Reporters now are enjoying the pay for performance nutty analytics too out there if you have not take note...gotta get those hits to increase the revenue from that ad exposure.  If you read the news it's all over the place so some agencies go for your emotional jugular and get you to comment and go wild with pouring out all those emotions.

So yes, the copy and paste deal it's a big joke to any who write software and to the doctors that use EMRs...and again come off the heads of folks who have no data logic and many of them who have never spent time with doctors observing what they do and how they do it.  Had a CEO of a big firm tell me not too long ago that the folks that market the revenue accounting software just have not a clue on how difficult it is for doctors to document today and they just off in some other world when it comes to these discussion, totally out of looking at what the doctors do, just want that sale!

It falls back to a lot of quantitated justificaitons at time for things that are just not true..and thinking you can take copy and paste away, it is big joke.  Here's some information about the rise of the journobot if you want to take a look and see how this works too..Charlie has a new book in the works at NYU with a chapter devoted to the rise of the journobt, I used a clip of one of his lectures on "context is everything" here.


User Rank: Author
1/27/2014 | 4:39:48 PM
From a patient's point of view
It's been intereting watching two different approaches: One doctor I go to switched to EHRs and now spends more of our meeting time checking boxes and trying to type w/ a stylus on his tablet that in actually discussing my situation. The other doctor dictates a report to a transcribing service.  He's done in a third of the time, and the report probably catpures what matters most.  If I was an busy doctor, trying to balance care vs reporting, I'd say the dictation route seems faster, but not every doctor may be good at it.  I'm sympathetic to whatever improvements can be made to improve EHR productivity and patient care.  But there ought to be software that identifies possible duplication abuses and errors.
User Rank: Author
1/27/2014 | 2:10:35 PM
Re: What's the alternative?
When I met with UPMC last year, they talked about the cut-and-paste problem. Doctors did it for efficiency for in-hospital progress notes, but that turned what used to be a concise half-page "what's happening" summary into 19 page documents. A top exec called it "an ongoing patient blog" that didn't give caregivers what they needed.
David F. Carr
David F. Carr,
User Rank: Author
1/27/2014 | 1:36:10 PM
Re: What's the alternative?
We also want a rich data trail to analyze for evidence of what care was delivered and whether it worked. We want lots of contradictory things. Balance is the big challenge.
Mr. Gigabob
Mr. Gigabob,
User Rank: Strategist
1/27/2014 | 12:17:36 PM
Re: What's the alternative?
Terribly ironic that "regulators" who aren't doctors, don't seem to recognize the basic truth - even the most basic EHR is a highly complex array of assualting boxes options and choices, but doctors can't spend a day or more to customize each entry - there are just too many to make.  Cut and paste - then edit is a standard practice for all personnel handling any sort of regular reporting process.  I am anxiously waiting for a "Smart EHR" just like a self driving car.

User Rank: Author
1/27/2014 | 12:11:42 PM
Re: What's the alternative?
Copy and paste -- but then modify for each patient. Perhaps this is the template approach. But in the end we want doctors to focus more on patient care, less on administrative minutia. 
David F. Carr
David F. Carr,
User Rank: Author
1/27/2014 | 11:04:15 AM
What's the alternative?
If you are going to tell physicians they are not allowed to use a technique that boosts their productivity by reducing redundant data entry, you had better have a better alternative to offer them. Template-driven systems might be it, although there's the same issue of potentially including too much boilerplate material and not correcting enough for the exceptions.

I was just speaking about this issue with Peter Basch, Medical Director, Ambulatory EHR and Health IT Policy at MedStar Health, who said he worries that tests for fraud based on multiple medical notes being too similar to each other conflict with another best practices trend in medicine - the use of checklists by physicians who are trying to make sure they provide care more consistently. Reducing variation can be one way of achieving higher quality. But if the government really goes to war over copy-and-paste medical records, it could wind up punishing consistency.

Both the productivity techniques and the scrutiny over their misuse need to be applied sensibly. Vigalance against true fraud can't be allowed to sabotage legitimate efforts to make the use of EHRs more productive.
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