Copy That: Are You In Compliance?

Diana Warner, MS, RHIA , CHPS, FAHIMADirector, HIM Practice Excellence, AHIMA

Agenda

• Identify benefits and risks of using copy and paste functionality

• Identify auditing best practices• Examine how to define, support, and

execute best practices • Describe how information

governance applies to the integrity of the health record

Reported Errors Make Headlines• American Medical News: EHRs:

“Sloppy and paste” endures despite patient safety risk

• EHR Intelligence: EHR patient notes: What’s wrong with cloning, anyway?

Risks

• Information Integrity– Inaccurate data– Redundant information– Inability to identify original source of

data– Propagation of inaccurate data

Copy and Paste Challenges• Outdated histories• Outdated labs• Entire chart note• Taking credit for interpretations • Attributions not documented • Spelling errors, formatting issues

Inappropriate Use

• Erroneous Error – 2 charts open at one time

• Provider – copied and pasted the office visit into the next 10 visits

• 60 page chart note• Chart note documentation not

unique to visit• Bill multiple times for one procedure

Clinical Trustworthiness

• Distrust of information• Patient care

Appropriate Use

• Demographics • Medications • Allergies • Problems • Labs and treatment or therapies

Healthcare Fraud

• Fraud is defined as an “intentional deception or misrepresentation that the individual or entity makes knowing that the misrepresentation could result in some unauthorized benefit to the individual, to the entity or to some other party”

Fraud and Abuse• Included in OIG 2012 Work Plan• “worded alike, or similar to other

entries”• Inconsistent documentation affects

coding and quality reporting• Volume of information does not

equal quality information• Pattern of inaccurate reporting may

be considered abuse

Auditing for Compliance

• Lawsuits• Risk Management– Organizational level– Vendor level

• Procedures

Develop an Audit Plan• How and when audits will be conducted • Who will perform the audits • Frequency for performing the audit • Time period covered by the audit • How the sample size is determined • Describe the outcome indicators • How will copy functionalities within the

record are identified • A corrective action plan based on findings

Create A Work List• Can a copy event be identified

retrospectively? • Is an appropriately detailed audit log

generated when a copy event occurs in the course of documentation?

Understand EHR Functions and Features• Is information copied forward

distinctive?• Audit trails included in EHR system• Blocks of content should be

individually authenticated• Identify re-authenticated information

Current Organizational Status

Discovery Phase• Policies and Procedures• Current Practices– Risk and Mitigating Factors

• Ongoing oversight – Education programs– Training programs– Auditing programs

Organizational Questions• Is there an alternative to copying data in the

EHR?• Who is responsible for ensuring that all copy

policies and procedures are enforced?• Who will perform ongoing audits of provider

documentation for appropriate use of copy?• How are errors identified and corrected?• What audit trails are available?

More Questions• Does the organization know how its

systems copy functions can be used within the EHR?

• Has the organization identified how copy will be utilized within the EHR?

• Has the medical staff approved copy policy and procedures?

• Does the organization have a process for identifying and mitigating unacceptable functions or uses?

Alternatives• Dictation or transcription • Voice recognition • Medical Scribes • Citing

– Active problems from problem list – Current medication from medication list – Allergies – Current labs

Additional Alternatives

• Templates – Drop down menus – Check boxes

• Macros – Phrases that are used routinely and can be populated

automatically

Education

• Review organizational policies on copy/paste in documentation

• Review sanction policy• Review audit policy• Train user on EHR workflow for

accepted copy and paste entries

Information Governance

• Information is an asset• Manage integrity through an

enterprise information management (EIM) program

How to Maintain Integrity• Commitment to conduct business and provide

care in an ethical manner • Purchasing systems that have capabilities to

prevent or discourage fraudulent activity • Implementing and following policies,

procedures, and system functions to prevent fraud

• Ensure the end product is compliant with all billing, coding, documentation, regulatory, and payer guidelines

• Ensuring documentation integrity in the record is a fundamental practice.

Information Governance

There is an increasing need to ensure healthcare information is trustworthy and actionable

Diana WarnerDiana.Warner@ahima.org

Questions?