The basic intention underlying the transition from paper-based documents to the Electronic Health Record (EHR) system is to improve patient care and reduce costs. The federal government has announced that health care practitioners who fail to achieve ‘meaningful use’ of EHR by 2015 will have to face reductions in Medicare reimbursements. However, it has been found that the EHR cut-and-paste function is making the system easily prone to errors – whether intentional or not.
Seriousness of Cloning Errors in Electronic Health Records
The main reasons for EHR copy and paste errors are:
- Doctors illegally upcode patients’ medical conditions and overcharge them for the care they are providing
- The cloning function can cause some part of the information to get truncated, which can lead to serious issues. For example, an article in Healthcare IT News reported on the case of a patient who had a “family history of breast cancer” wrongly entered as “a history of breast cancer”.
- Physicians accidentally copy exam result of one patient to the record of another patient
- Incorrect information recorded in the EHR will be widely distributed (EHR of patients can be transferred or connected to pharmacy section, lab section, and so on)
- Several health centers/hospitals just are making their transition from paper based records and using both the systems (paper documents and EHR) in tandem causes incomplete information to be transferred from one source to another.
These issues actually happen and the authorities have failed to come up with proper rules or guidelines on how to use the copy and paste function. Improper use of cloning function is leading to serious medical billing errors, compliance and payment problems.
How to Resolve Errors caused by Cloning
- Creating strong standards for validating electronic health records is one of the possible options. This ensures the proposed benefits and protects taxpayers from fraud, waste and abuse.
- Developing better guidelines for Medicare contractors can help in determining the cases of fraud by reviewing changes to specific patient documents much closely.
Doctors use the cloning function as it reduces the time spent on documentation and makes their job seemingly easier. But the problem is that these benefits should be enjoyed without the fear of fraud and abuse. For this, physicians must be familiar with the features of EHR and the methods to use them properly. In general, the right option is to avoid copying information all together to avoid problems related to patient care or medical billing issues.