The Story in Short:
Few these days can argue against the truth that EHRs have become an indispensable part of the healthcare delivery system. But like any new-age technological advancement, they have their set of pros and cons, with the cons sometimes coming to the forefront when certain best practices are not followed.
There is no denying the fact that EHRs have made real the goal of seamless medicine and have greatly enhanced the efficiencies of both providers and support staff, while at the same time making the storage and retrieval of patients’ records a dream.
With so many things going in their favor, it was only natural that in time a small group of detractors started pointing out seemingly significant snags when it comes to their usage. One functionality of an EHR which often bears the brunt of their attack is the ctrl copy + ctrl paste process within its confines.
The AHIMA EHR Toolkit:
Any medical billing vendor worth his salt would have surely heard about the AHIMA EHR Toolkit, which talks among other things extreme caution to be exercised when it comes to copying and pasting a patient’s old medical records content into their latest visit. Although there could be many reasons for someone doing this, including obviously saving on precious staff time by avoiding the keying of redundant patient information; the most significant one could be the fact that the providers themselves dictate so.
A client of BillingParadise, a medical billing and medical coding vendor had the following to divulge when it came to the practice of using the copy + paste function within an EMR.
“ Our general practitioners need to perform regular follow-ups on multiple patients on a daily basis. It stands to reason that when they do come around to dictating notes, they don’t linger unnecessarily on things which have been ‘status quo’ and instruct the EHR handler to retrieve and use pertinent information from the old records. “
Thus, as can be seen in the above scenario, it is really not upto the EHR handler to decide if he/she is going to utilize older patient records. The situation and the dictator make sure that that is the only option left to pursue.
CHDA (Certified Health Data Analysts) Make the Difference:
So what then is the reason for OIG audits yielding data pointing to inaccurate documentation of E/M visits, leading to errors in E/M coding and billing? Is the copy + paste functionality really to be blamed for this? The answer could be that certain best practices could have been bypassed by the inhouse documentation staff when it came to using the copy + paste functionality. Some of these practices are outlined below:
a. Proofing the copied information for inaccuracies.
b. The pertinence of the information to ongoing care of the patient.
c. Making sure the information is pasted into the right chart.
It is highly unlikely that an inhouse documentation staff, unburdened by the need to acquire professional certifications, would be heeding all of the above, and thus OIG’s laments are easily explained.
On the contrary, it has been empirically observed that a dedicated medical billing vendor, properly certified in the usage of EMRs, and having a plethora of Certified Health Data Analysts on its rolls, rarely ends up brushing OIG the wrong way when it comes to proper and accurate medical records documentation in the EHRs.
