Part 1 - How to Ensure Proper Use of Electronic Health Record Features and Capabilities: Copy and Paste, Copy Forward and Cut and Paste

In June, 2016, the Centers for Medicare and Medicaid Services (CMS) issued a publication entitled “Ensuring Proper Use of Electronic Health Record Features and Capabilities.” The publication includes a decision table intended to help providers use common features of electronic health records (EHRs) appropriately. CMS first addressed the use of the copy and paste, copy forward and cut and paste features of EHRs.

The copy and paste feature allows users to use the content of another entry and to select information from an original or previous source to reproduce in another location. The copy forward capability replicates all or some information from a previous note to a current note, while the cut and paste feature removes documentation from the original location and places it in another location.

The use of these features raises a number of program integrity issues. Copy and paste can, for example, lead to redundant and inaccurate information in EHRs. The authorship of documentation may be unclear since it cannot be tracked to the original source.

In addition, such documentation lacks information specific to individual patients necessary to support services rendered to each patient. This lack of specificity can, in turn, affect the quality of care and can cause improper payments due to:

• False information about services provided to patients
• Coding from old or outdated information that may lead to “upcoding”

Recommendations to help ensure appropriate use of these features include:

• Develop and implement a policy governing the use of these features that balances efficiencies against the potential for inaccurate, fraudulent, and/or unmanageable documentation.
• Policies applicable to the use of these features should require practitioners to modify copied information to develop patient-specific content that is related to current visits and/or services.
• Policies governing the use of these features should also require proper notation and clear attribution of copied information.
• Providers should also monitor and audit the use of these features in the audit log. EHR systems should be enabled to record the method of each data entry, i.e., copy and paste or direct text entry, in order to enhance auditing capabilities.

According to CMS, best practices with regard to the use of these features include:

• Ensure that practitioners recognize documentation of each patient encounter as a stand-alone document.
• Documentation must reflect the level of services actually delivered and meet the requirements of various payor sources for billing and reimbursement.
• Validate each entry that is not authored by the user, including the name, date, time and source of information. Systems may be designed to routinely provide validation.
• Prohibit the use of the cut and paste feature, since it removes original source documentation.

The use of EHR has become essential to many providers, but resulting efficiencies may bring new problems and liabilities, if the features and capabilities of EHR are improperly used.

©2016 Elizabeth E. Hogue, Esq. All rights reserved.

No portion of this material may be reproduced in any form without the advance written permission of the author.