1. Copy-Paste The Good, The Bad, The Ugly
Jennie Bryan, MBA, RHIA, CCS
Compliance Audit Manager
Crowe Healthcare Risk Consulting
Anyone remember the movie, The Good, the Bad, the Ugly? It was a 1966 western featuring Clint Eastwood (The Good), Lee Van Cleef-Sentenza/Angel Eyes, The Bad and Eli Wallach-Tuco, The Ugly. I want you to keep the images of Clint Eastwood, Lee Van Cleef and Eli Wallach in your mind as we go through this presentation
Now to set the mood, let’s listen to a portion of the Theme Song.
November 9, 2018

2. Course Objectives At the end of this session, you should be able to:
Define copy/paste and other similar EHR functionality
Identify what is good, bad and ugly about this functionality
Identify methods to assess and mitigate risks

3. Activity: POLL
I would like to determine what experience you have with Copy/Paste.
By show of hands
How many of you read electronic medical record documentation every day?
How many of you use that information to code?
How many of you use that information to make patient care decisions?
How many of you use that information to substantiate a service provided?
How many of you audit that information and provide feedback to providers/clinicians?
Does you notice instances of copy/paste

4. EHR Adoption By Hospitals
Why are we talking about this? Because EHR has become the norm. This graphic shows EHR adoption by hospitals, specifically those eligible hospitals and critical access hospitals that have demonstrated Meaningful Use. .

5. EHR Adoption by Physicians
As in the last slide, this one demonstrates the adoption of EHR by MDs. They are lagging behind hospitals but EHRs are on the rise.
As we have gone electronic, the use of copy/paste has increased. The University of Southern California San Francisco published a study in JAMA (2017). They looked at thousands of progress notes, written by nearly 500 clinicians over 8 months in the UCSF Medical Center’s inpatient Epic EHR. They found more than 80% of the notes were imported or copied from elsewhere. They were able to further identify that 46% of notes were copied, 36% were imported and 18% were text entered manual. - Per Wang MD, Khanna R, Najafi N>JAMA Intern Med. 2017;177(8): doi: /jamainternmed Study at University of California San Francisco Medical Center. Epic.
This is just one study, there are many others that demonstrate the high use of Copy/Paste.

6. Definitions
Copy-reproducing text or other data from a source to a destination._Ascension Define
Copy + Paste- Really refers to a process. It is the process of selecting text or objects from one digital document and is imported unchanged into another document. Other common terms are copy-forward, pull-forward, carry-forward_Ascension Define
Cloning-typically referred to when the medical records are the same or nearly the same, or appear to be the same as previous records. When CPF is used so excessively and inappropriately, it brings the credibility of the medical record into questions. So, this could be the duplication of note (perhaps from same patient to same patient or from one patient to another patient). This is typically there is little to no editing. _Ascension Define

7. THE GOOD
So go back to our Movie and think Clint Eastwood. He played Blondie.

8. The Good - Benefits of Copy/Paste
Saves time for the clinician
Creates efficiency capturing information
Reduces transcription error
Improves the ability to track multiple issues in highly complex patients
Improves completeness of encounter documentation
Saves time for the clinician allowing them to hopefully spend more one on one time with the patient.
Creates efficiency capturing complex information
Reduces transcription error as the documenter is not typing or if they were dictating, the transcriber didn’t make an error
Provides a better mechanism to track highly complex patients with multiple issues. In that this complex information can be copied and pasted as the patient moves through the healthcare system. This information has to be verified and validated for each encounter or we get into the “bad” or “ugly” phase quickly
As it is easier and less time consuming providers are more likely to provide complete documentation.
Can anyone add to this list?

9. The BAD
Again back to our Movie. Lee Van Cleef-Sentenza/Angel Eyes plays the bad guy.

10. The Bad - Risks of Copy/Paste
Data integrity (outdated, inaccurate)
Note bloat
Repetitious or irrelevant information
Author attribution/integrity
Inability to identify when the information was first created
Inability to accurately support or defend E/M codes for billing
Data integrity-if the provider does not review the information to make sure it is current and accurate, the information can be continue to be propagated for a long time. Sometimes years. Propagation of errors over time. What if it is inaccurate or outdated. This might impact patient care.
Note bloat-the ability to easily move information from one day to the next or one encounter to the next, autopopulate, etc. Can lead to notes that are pages and pages in length. The information that is “new” to that day or encounter can be buried in the bloat. This can be overwhelming to the reader. Long notes that don’t clearly convey the current status of the patient. Can actually be distracting.
Repetitious or irrelevant information- Similar to what we have talked about for data integrity and note bloat. Notes contain the same information over and over. Some of which is no longer relevant to the patient’s current care. Cloud the judgement of providers by including information that is no longer pertinent or wrong (i.e. PE-pulmonary embolism vs physical exam) constantly brought forward to other notes until people think it was pulmonary embolism hx and order testing. When it was physical exam.
Author attribution-it can be difficult to determine who authored what portion or which portion of the note. Inaccurate representation of authorship of documentation. (Plagiarism) Duplication of inapplicable information. Incorporation of misleading or wrong documentation due to the loss of context for users that was available from the original source. Ability to take over a record and become the author. Inclusion of entries from documentation created by others without their consent. Inability to accurately determine services and finding specific to a patient’s encounter.
Inability to identify when the information was first created
E/M code defense-if you can’t tell what work the physician did on that day or encounter, you can’t defend the E/M billed.

11. The UGLY
Back to our movie. Picture Eli Wallach as the Ugly. He was Tuco

12. The Ugly - Billing, Fraud and Abuse
Billing Concerns
Fraud and Abuse
Record doesn’t stand up to litigation
So we have talked about what is bad. If there is enough bad it can turn very ugly, quickly.
Billing Concerns-
CMS Medicare Claims Processing Manual Chpt 12, Section says that providers are to “select the code for the services based upon the content of the service” and that “documentation should support the level of service reported.” The OIG has included Copy/Paste in their Work Plan.
Here is a quote FROM TESTIMONY OF LEWIS MORRIS, OIG-“For example, electronic health records (EHR) may not only facilitate more accurate billing and increased quality of care, but also fraudulent billing. The very aspects of EHRs that make a physician’s job easier—cut-and-paste features and templates—can also be used to fabricate information that results in improper payments and leaves inaccurate, and therefore potentially dangerous, information in the patient record. And because the evidence of such improper behavior may be in entirely electronic form, law enforcement will have to develop new investigation techniques to supplement the traditional methods used to examine the authenticity and accuracy of paper records. “
Underline added for emphasis
Inappropriate copy/paste could facilitate attempts to inflate claims and duplicate or create fraudulent claims
The use of templates could encourage or suggest providers perform more comprehensive services that were actually rendered or necessary. Example – Physical Exam included exam of Cranial Nerves II-XII were grossly intact. Is this necessary for all patients. Probably not. Is it really necessary to document 8 or more body areas/systems for every patient. Probably not. This is what the OIG is worried about.
Inaccurate diagnosis codes (if MD is autopopulating problem lists, copying diagnoses that are not currently being treated)
Billing concerns can certainly lead to Fraud and Abuse and False Claims.
Litigation – The health record is the business record of the organization. So, during litigation, organizations can be required to produced the record. It is important that the record be accurate and the integrity of the record is credible and sustainable over time. As we have discussed redundancy makes it difficult to identify what information is pertinent to the care of the patient at a certain point in time. There is the risk of propagating misinformation which can lead to patient safety issues.

13. The Ugly – Quality of Patient Care
Last but certainly not least is how copy/paste impacts the quality of patient care.
Consider
The information not pertaining to the patient is in their medical record. Something simple, like they are a smoker but they aren’t. Something more complex as I will demonstrate later
The information is out of date (i.e. medications, diagnoses no longer being treated)
Note bloat leads to providers/clinicians overlooking documentation that is important.
Video-Danger of EHRs- They are a contributing factor to malpractice claims has increased over recent years. Copy/Paste errors have contributed in 14% of these claims. These cases are from the Doctors Company EHR Closed Claims Study.

14. Activity: POLL
By show of hands? You can answer for both groups if you have a foot in both worlds.
What hospital systems are you using?
Epic
Cerner
Meditech
Other?
What physician systems are you using?
Allscripts
eClinicalWorks
NextGen

15. Example 1 Example #1-Meditech Inpatient progress note.
Reviewed this note again the prior day’s progress note 5/24/18
Red is COPIED

16. Example 2 Example 2 – Epic Inpatient
Compared note to previous day’s note
Green-added by current author
Red-Copy/Pasted, Epic sources it from the place it was copied. However, if it is repeatedly copied, it doesn’t source the original document.
No highlight-it is some other functionality like Smart Link. Smart Word

17. How to Mitigate Risk1
Provide a mechanism to make copy and paste material easily identifiable
Ensure that the provenance (chronology of ownership) of copy and paste material is readily available.
Ensure adequate staff training and education regarding the appropriate and safe use of copy and paste.
Ensure that copy and paste practices are regularly monitored, measured, and assessed.
These are recommendations from ECRI Institute
Easily identifiable -No matter how documentation is created, it must be accurate, reliable, and timely. Copy/pasted material must be verified prior to final submission. In order to make that validation process easier, the material should be easily identifiable. So how might this be accomplished?
Visible in a split screen
Visible by hovering
Shows as a different format (italics, different color)
Chronology of Ownership -Why is this important? In order to ensure accuracy, reliability and appropriateness of information used to make clinical decisions, it is necessary to know the source, context, author, time and date of the source information. If providers/clinicians are relying on inaccurate information can negatively impact patient care and patient safety.
Training -Standardize the process to ensure all staff are following appropriate and best practice guidelines. Standardization helps to ensure regulatory compliance, litigation
Monitoring – Audit trails, audit policy related to copy/paste. Identifies when copy/paste is used and by whom. Monitoring can identify that policies and procedures are working as intended. Can assist in developing alternative methods to copy and paste.
1ECRInstitute. Partnership for Health IT Patient Safety. Health IT Safe Practices: Toolkit for the Safe Use of Copy and Paste

18. More
Have a policy, set guidelines-develop a consensus around the appropriate use of CPF (more difficult than it sounds)
Provide input to vendors
Copied material must be sourced
Identified process to report inaccuracies or misuse
Disciplinary policy
Policy – There are resources out there that provide sample policies (AHIMA, ECRI)
Vendors – Push vendors for ways to easily identify copy/paste material (Epic). Push vendors for reports that identify the use of copy/paste (by provider)
Sourcing – any copied/imported documentation should be sourced (author, date, etc.)

19. What is the Author’s Responsibility?
Accuracy
Source Attribution
Brevity
Use of copy/paste only in appropriate contexts
Author Responsibilities
Taken from ECRInstitute Copy/Paste: Prevalence, Problems and Best Practices-Special Report
Follow the organization’s EHR documentation policy
Verify the accuracy of all copied content regardless of the source
Document/acknowledge the original source of the copied text
Authors should strive for brevity
Understand when it is appropriate to use copy/paste and only use it in those scenarios.

21. Risk Assessment Questions - Vendor
Can Copy/Paste be easily identified in the record?
Are there ways to monitor it’s use?
Are there other alternatives/functionality that can be used to discourage the use of copy/paste?
Is the original source (date, time, author) of the information visible in the record?
Is the original source information traceable in the audit functionalities?
These are questions that can or should be asked of your EHR vendor.

22. Risk Assessment Questions - Organizational
Does the organization have an EHR documentation policy and/or Copy/Paste Policy?
Have all stakeholders been educated regarding the policy or education specific to safe uses of copy/paste?
Do we track the use of copy/paste?
Do we incorporate documentation (the use of copy/paste) into peer review activities?
Are we encouraging vendors develop technologies to facilitate safe use and tracking of copy/paste?
Does the organization have a process in place to identify and correct incorrect information?
Is there a corrective disciplinary plan?
Do we track the use of copy/paste?
Are there reports generated out of the EHR platform? (Cerner has reports that can show the % of a note that is copied). Epic-
Who is responsible for tracking?
Is there a process in place to identify incorrect information?
Who can correct incorrect information, how is the accomplished?
Who investigates how the incorrect information was entered?
What is the process to ensure corrections are made in ALL systems and updated to ALL providers?
Disciplinary Action
Failure to comply with the organization policy regarding copy functionality may be deemed a violation of the Bylaws of ABC Medical Staff.
Further disciplinary action may be taken by the VP of Medical Affairs or Chief Medical Officer if violations of this policy are substantiated.

23. Why Should HIM Care?
HIM professionals are responsible for overall documentation integrity
HIM professionals are directly affected by documentation practices
HIM professionals are uniquely qualified to identify gaps within EHRs
HIM professionals are uniquely qualified to provide strategies for auditing documentation
HIM professionals are not only responsible for overall documentation integrity; they are also directly affected documentation practices. For example, information that is inconsistent and ambiguous in the documentation directly affects the coding professional’s ability to accurately assign the diagnosis and procedure codes based on the information documented. _AHIMA Copy/Paste Toolkit
HIM professionals must have sufficient knowledge of the copy capabilities in the organization’s EHR and must, where applicable, identify gaps within the current electronic systems and provide strategies for auditing documentation that is copied from elsewhere in the EHR. Any deviations that prevent tracking and auditing need to be documented as known issues within the system. AHIMA Copy/Paste Toolkit
The HIM professional is obliged to know, understand, and manage copy functionality to support EHR documentation quality. The HIM professional must also work closely with the organization’s IT department and technical system vendors. Availability and management of the copy functionality are in turn based on the individual EHR system’s functionality and may be further determined by the unique way that a given organization has implemented that system. _AHIMA Copy/Paste Toolkit

24. Implement policies and procedures
Key Takeaways!
Implement policies and procedures
Educate Physicians
Monitor
Implement Policies and Procedures that define Copy/Paste and it’s appropriate use

25. References
AHIMA. “Copy Functionality Toolkit-A Practical Guide: Information Management and Governance for Copy Functions in Electronic Health Record Systems.”
AHIMA.“Auditing Copy and Paste” Journal of AHIMA 80, no.1 (January 2009):
Partnership for Health IT Patient Safety. ECRI Institute. “Health IT Safe Practices: Toolkit for the Safe Use of Copy and Paste”. February
ECRI Institute, Special Report. “Copy/Paste: Prevalence, Problems, and Best Practices.” October
You Tube. TEDx Talks. EHR: The Inflection Point of Medicine: Sunil Bhoyrul.
Senator Warren discusses the importance of accurate electronic medical records. (Senate Hearing)

26. Jennie Bryan, MBA, RHIA, CCS
Compliance Audit Manager
Crowe Healthcare Consulting