Documentation integrity is critical for avoiding fraudulent billing, HIPAA violations, claim denials, audits and compliance violations, and threats to patient care. Unfortunately, certain practices used within electronic health records (EHRs) can be problematic. For example, as EHR continues to rapidly replace paper records, the use of cloning – also known as copy and paste or pulling forward – in clinical documentation has significantly increased as well. While this practice may have some time-saving benefits, it can also damage the integrity of the patient record.

WHAT IS CLONING?

Cloning refers to copying and pasting notes from one patient encounter to another without updating the information. It’s also considered cloning when entries in the medical record are worded the exact same or very similar to previous notations. To meet medical necessity requirements for Medicare, documentation for each provided health service must be distinct from one another.

EHR-RELATED FRAUD AND ABUSE

Cloning has been identified as a problem area by the Office of Inspector General (OIG) and for years has cautioned that cloning makes it too easy for providers to inflate claims or create false ones. In a report from 2014, the OIG noted, “When doctors, nurses, or other clinicians copy-paste information but fail to update it or ensure accuracy, inaccurate information may enter the patient’s medical record and inappropriate charges may be billed to patients and third-party health care payers. Furthermore, inappropriate copy-pasting could facilitate attempts to inflate claims and duplicate or create fraudulent claims.”

The report also addressed overdocumentation and how duplicate and excessive information causes contradictions in records “…suggesting the practitioner performed more comprehensive services than were actually rendered.”¹

PATIENT HARM ATTRIBUTED TO CLONING

A medical record is only useful for clinical decision-making if it’s a trustworthy source. Confusion arises when information is contradictory or hard to find, and this can lead to poor clinical decisions affecting the lives and well-being of patients. Copy-pasting has been identified in the Joint Commission’s sentinel event database as the root cause leading to several reports of patient harm. Examples of documentation errors that have led to harm include outdated weight information used for dose calculation of chemotherapeutic agents and lengthy progress notes that prevented timely and efficient communication.²

REDUCE YOUR RISK

Cloning can be done responsibly if the proper steps are taken to ensure records are complete and accurate, containing all the elements essential to creating a narrative for patient care. Records should include documentation that shows the status of patients, their needs at each visit or encounter, and the care plans to address those needs.

The American Health Information Management Association’s official position on cloning in EHRs states that it “should be permitted only in the presence of strong technical and administrative controls which include organizational policies and procedures, requirements for participation in user training and education, and ongoing monitoring. Users of the copy/paste functionality should weigh the efficiency and time savings benefits it provides against the potential for creating inaccurate, fraudulent, or unwieldy documentation.”

Similar stances are taken by the Joint Commission patient safety alert, “Preventing Copy and Paste Errors in Electronic Health Records,” and OIG studies on electronic health record integrity.

Excelas can quickly and thoroughly review your records to identify errors related to cloning.

In 2017, we reviewed more than 2 million pages of records. Our findings were:

90% of the records received were incomplete and gaps in documentation were identified and reported
20% were not HIPAA compliant
16% contained inconsistent entries with copy-pasting identified as an area of risk
To talk to someone about the services we offer, Call or email us today!

Resources:

1 Levinson, Daniel R. CMS and Its Contractors Have Adopted Few Program Integrity Practices to Address Vulnerabilities in EHRs. 2014

2 “Preventing Copy-and-Paste in EHRs.” Quick Safety, no. 10, Feb. 2015, www.jointcommission.org/assets/1/23/Quick_Safety_Issue_10.pdf.