Coding, Classification & Reimbursement

EMR Cut & Pasting

  • 1.  EMR Cut & Pasting

    Posted 09-06-2018 09:48
    ​​Hello!

    I have been tempted to post a comment on this subject in the past.  Without going into detail, my current position has prompted me to act.

    I have recently done some research which indicates the "Cut & Paste" problem was known as far back as 2014, maybe 2013 (or earlier).  The problem has been referenced by AHIMA, AMA, and JCAHO.  While the problem has been recognized, I am wondering if any concrete actions have been taken.  The problem has been compounded by the increased use of CAC Encoder Systems.

    Any comments including recent personal experiences with this problem would be appreciated.

    I am keeping this post intentionally brief for now.  I have one more comment which until now I have kept to myself.  If this problem is as wide spread at other facilities as at my current situation, someone is going to die because of inaccurate documentation, if it has not happened at least once already.

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    Lawrence Barr
    President
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  • 2.  RE: EMR Cut & Pasting

    Posted 09-06-2018 12:35
    This is what I understand is the vision that would solve this kind of concerns.


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  • 3.  RE: EMR Cut & Pasting

    Posted 09-07-2018 08:44
    Lawrence,
    Thanks for a great post!  This has been problematic since we started implementing electronic records.  I was part of an implementation 20 years ago and we identified this as an issue then but had the capacity to "lock down" the chart entry to eliminate this issue.  Of course, with the flexibility of electronic records and the convenience this option is usually discarded now for convenience, efficiency, etc.

    I totally agree with you that it is completely out of hand and does not seem to be addressed effectively by any of the cooperating parties, regulatory agencies or quality control.  And, as you stated, it has been severely compounded with the CAC encoder systems that are being widely used and touted as the answer to speeding up the dropping of bills and getting the data out the door.

    This is a problem that spans the nation as I have seen progress notes duplicated in series in many facility records.  The issue is that most clinicians who have access to documenting in the record have this capability to "copy/cut & paste" at will.  It becomes extremely difficult to read, review and under the entries in the record with many electronic environment - you simply cannot tell what is copy/pasted versus the current entry (or if there is a current entry).  This practice also increases the size of the record with all the duplication.

    As HIM practitioners we need to seriously start measures to correct this very dangerous practice and get some corrective actions implemented quickly.  With all the emphasis on data governance and medical errors (which get a ton more press) I think this type of error has been swept under the carpet and is ignored in an effort to alleviate some of the grumbling around the electronic record and the access issues involved.

    Thanks again for bringing up a very dire topic.  I would be happy to help in any way to get some focus on how we can work on these issues before we have serious consequences.

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    Cheryl Bowling, RHIT, CCS, CHC, C-CDI
    Client Compliance Partner
    samstaff
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  • 4.  RE: EMR Cut & Pasting

    Posted 09-07-2018 09:43

    This is a true epidemic.  We are beginning to audit "copy and pasting".  However, it is still a manual process and providers are referred to me by my coders or our Care Coordinators, who review records and often have to send documentation to the insurance company for continued stay.

     

    We have a new CMO who is invested in quality documentation.  Once a provider is referred to me, I will do an audit and present to the CMO.  He will have a one-on-one conversation with the provider.  After that, I re-audit weeks later.  While this is not a written policy, this is what we have morphed into doing recently.  Also, I purchased a DVD on cutting and pasting and will use it as part of education.  While I haven't personally viewed it yet, I plan to in the near future.  We also engaged our Education Department to devise a "mini" test (8 questions) that must be completed.  The thought process is if a provider is referred for an audit, besides the conversation with the CMO, they would be required to view DVD and take the test. 

     

    Again, I don't have this in a formalized policy/procedure yet, but wanted to share what we are doing. 

    Once I view the DVD, I will post the name, etc.

    Donna

     






  • 5.  RE: EMR Cut & Pasting

    Posted 09-08-2018 08:14
    ​Hello!

    Based on most of the responses I am glad I decided to start this topic.  Again, my current position prompted this topic.  This problem where I am coding is rampant.  One example - Results of a CT scan with a diagnosis of pulmonary embolism were repeatedly copied and pasted into the current record.  Fortunately, I discovered the CT scan was from sometime in 2017 before I assigned the code for PE.

    For now, a few other observations and questions.

    It appears to me that EMR vendors decided they were not only going to convert the paper record to an electronic format but also improve upon the structure and content of the documents.  The structure and content of the medical record was not arrived at overnight.  It was based on years of experience.  The problem is especially apparent with "The Progress Note".

    Besides the "Past Medical History" in the H&P, Consults, and Discharge Summary, there is no good reason to repeat the same documentation over and over again.  This is especially true of conditions not involving the current encounter. With certain rare exceptions, progress notes should really be limited to the patient's "progress" since the previous encounter

    CDI is not really involved with "Documentation Improvement".  CDI involves assuring certain conditions which affect DRG assignment are properly documented.  It has nothing to do with the actual quality of the entire medical record

    Regardless of the quality of the medical record documentation, the coder is ultimately held responsible for "mistakes".  It seems only coders are subject to audits.  It is the coders responsibility to reconcile the difference between the coder's DRG and the CDI DRG.  Auditors apparently are not audited.

    I am encouraged to see others are concerned with this situation.  Another reason I initiated this topic is the apparent lack of concern I have been experiencing.  In the past when I have broached this problem with HIM management the response has been very consistent.  "Yes, we know.  Do the best you can."

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    Lawrence Barr
    President
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  • 6.  RE: EMR Cut & Pasting

    Posted 09-08-2018 06:39
    ​Lawrence,
    It's a horrible problem, one that hospitals/clinics could stop before it starts when they bring a new EHR system on board. However, they rarely think of locking the ability to copy/cut/paste out of the system.

    CMS is no help. I watched the CMS Panel Discussion on E/M Coding Reform on July 18, 2018 (on YouTube).
    Seema Verma starts right off singing the blues about E/M documentation and makes it sound like the only reason to document is for billing.
    She states "The requirements often mean that doctors have to cut and paste chunks of information across medical records strictly for billing purposes." (I yelled at the computer screen!) With that comment, my hopes sunk for any assistance we could get from them.


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    Ann Waters, RHIT, CCS
    Consultant
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  • 7.  RE: EMR Cut & Pasting

    Posted 09-11-2018 11:48
    ​This is a problem at my facility as well.   Creates much confusion with the coders as what is current and valid versus what is cut and paste.  We question whether the patient's condition has changed over the course of the hospital encounter.   We also are experiencing significant problems associated with the problem list as our doctors have multiple ways to pull in problem list information and it often has problems that are resolved but not removed from the list.  This data is then copied and pasted in to more notes and cycle continues.  Our system includes many templates for the doctors specific to whatever they wanted at time the system was configured which also leads to confusion.  Coder productivity has not really improved with the EMR.

    Thanks!

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    Karen Feltner , RHIA, CHDA, CCS
    HIM IP Coding Manager
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  • 8.  RE: EMR Cut & Pasting

    Posted 09-12-2018 11:28
    This is a huge issue and I agree that it is not discussed or taken nearly seriously enough. I've seen this in a hospital environment where I started my career and know how damaging it was in that environment. I currently work in skilled nursing and can say that it may even have a bigger impact here. CMS only requires that each patient be seen by a physician every 60 days and the notes from these encounters constitute pretty much the entirety of codeable documentation in the chart. But the physician's do not work for our company and they largely provide SNF services in addition to hospitalist duties at hospitals in our area, which makes us their lowest priority. They come in and see patients, but then just copy and paste whatever the last note said, even if the patient has had a change of condition or is experiencing an acute condition at that moment. This practice makes all of our physician documentation almost completely useless and potentially even dangerous. It is a known issue to upper management who have been trying for months to bring change in this area, but it just seems like with all the rules and regs in existence doctors are always the last ones held responsible for anything, on this or any issue.

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    Jacqueline Mccauley
    HIM Director
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