healthy4u: healthcare IT note cloning

EHR cut-and-paste problem is only one of the several mechanisms to clone documentation - and facilitate fraud

In my Dec. 10, 2013 post "<b>44% of hospitals reported to HHS that they can delete the contents of their EHR audit logs whenever they'd like"</b> (<a href="http://hcrenewal.blogspot.com/2013/12/44-of-hospitals-reported-to-oig-that.html">http://hcrenewal.blogspot.com/2013/12/44-of-hospitals-reported-to-oig-that.html</a>) I observed that the "money quote" of the Modern Healthcare article that prompted the post, "<b>Feds eye crackdown on cut-and-paste EHR fraud</b>" by <a href="mailto:jcarlson@modernhealthcare.com" target="_blank">Joe Carlson</a> was not the issue of EHR cut-and-paste features and billing fraud, but <i>EHRs and audit trail alteration.</i><br /><br />Dr. Stephen R. Levinson, an E/M compliance and healthcare quality expert among other areas of expertise (see <a href="http://www.linkedin.com/in/stephenlevinson">http://www.linkedin.com/in/stephenlevinson</a>), wrote me with the following regarding the issue I glossed over in favor of the audit trail concerns, namely, EHR cloning. <br /><br />Reproduced with Dr. Levinson's permission:<br /><br /><blockquote class="tr_bq">This long-recognized and high-profile problem <span style="color: red;"><i><b>[EHR cut and paste, copy forward, etc. - ed.]</b></i></span> covers only one of the several mechanisms EHRs provide to create CLONED Documentation.<br /><br />Other non-compliant short-cuts include documentation by exception (auto-entry of extensive negative history reviews and normal comprehensive examinations), use of restricted pick list words and phrases, and "translation."<br /><br />Translation is my own terminology for taking actively entered "yes" or "no" responses in medical history (and "normal" or "abnormal" findings in physical exam) and using pre-loaded software to convert (i.e., translate) the response to a long pseudo dictation paragraph. For example, check a box for lungs being "normal" may automatically appear in a paragraph as "lungs clear to percussion and auscultation; respiratory effort is normal on inspiration and expiration with normal excursions of the diaphragm; there are no rales or rhonchi, and no wheezes are present."<br /><br />This extended statement will appear identically in patient after patient and visit after visit, regardless of whether this level exam was performed. Further, the likelihood of every patient having completely normal lungs is non-existent.<i><b>  </b><span style="color: red;"><b>[This is one mechanism by which reams of "legible gibberish" are produced even with modest hospital stays, e.g., see my Feb. 27, 2011 post "Two Weeks, Two Reams" at </b></span><a href="http://hcrenewal.blogspot.com/2011/02/electronic-medical-records-two-weeks.html">http://hcrenewal.blogspot.com/2011/02/electronic-medical-records-two-weeks.html</a><b> <span style="color: red;">- ed.]</span></b></i><br /><br />Finally, although cloned documentation is egregious, there are four other equally egregious non-compliant documentation and coding features, common to most EHRs, that are being totally ignored by OIG. These 4 features are:<br /><br />1) non-compliant coding engines (including failure to consider medical necessity of the level of care)<br /><br />2) Replacing narrative documentation of differential diagnoses with billing codes (ICD-9) and billing semantics<br /><br />3) Failure to document the qualitative components of E/M coding, while addressing only quantitative components (e.g., when patient has a positive response to review of systems question on chest pain, compliance (and quality care) requires further investigation and documentation of further details; most current systems either lack ability to document these details or fail to guide and require physicians to document them)<br /><br />4) Failure to incorporate consideration of "medical necessity" (indicated in E/M coding as the "nature of the presenting problems") into care, documentation, and coding</blockquote><br />As evidenced by these explanations, common commercial EHRs in use today were either designed by amateurs or by crooks, with the gatekeepers turning a blind eye towards abuses since at least 2007 (per commenter and EHR compliance expert Dr. Reed Gelzer who, at <a href="http://hcrenewal.blogspot.com/2013/12/44-of-hospitals-reported-to-oig-that.html">http://hcrenewal.blogspot.com/2013/12/44-of-hospitals-reported-to-oig-that.html</a>, indicated ONC and OIG knew of these issues since a 2007 report he contributed to).<br /><br />The gatekeepers have turned a blind eye, that is, until now when they've finally opened one eye very slightly, like a ten-day-old puppy, as the abuses become more widely known.<br /><br /><br /><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhdGG663K2XijBFNigZfHwVmLpFLgpCBrFX0e5PhiNJncsHPqiOqeB4XYVVBnDx17jKEBObsuCBriTk4wzIYibrxTW8zOoHH84Rizg0YHVbEn59H-wqeC_O9ozMcYdy99UrcXKebsr1GoFC/s1600/week2-puppy2eyes.gif" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="151" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhdGG663K2XijBFNigZfHwVmLpFLgpCBrFX0e5PhiNJncsHPqiOqeB4XYVVBnDx17jKEBObsuCBriTk4wzIYibrxTW8zOoHH84Rizg0YHVbEn59H-wqeC_O9ozMcYdy99UrcXKebsr1GoFC/s200/week2-puppy2eyes.gif" width="200" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Young puppy begins to open its eyes.</td></tr></tbody></table><br /><br />-- SS

EHR cut-and-paste problem is only one of the several mechanisms to clone documentation - and facilitate fraud

In my Dec. 10, 2013 post " 44% of hospitals reported to HHS that they can delete the contents of their EHR audit logs whenever they...

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American Medical News: Dangers of "EHR Sloppy and Paste"

An American Medical News (<a href="http://amednews.com/" target="_blank">amednews.com</a>) article by Kevin O'Reilly appeared entitled "EHRs: 'Sloppy and paste' endures despite patient safety risk."<br /><br />It addresses the dangers of a common feature of EHR's used recklessly:  copy-and-paste. <br /><br /><blockquote class="tr_bq"><a href="http://www.ama-assn.org/amednews/2013/02/04/prl20204.htm" target="_blank">EHRs: “Sloppy and paste” endures despite patient safety risk</a><br /><br />Copying and pasting information is common within EHRs,  but the practice sometimes can lead to confusion and endanger patient  care. <br /><div id="Byline"><br /></div><div id="Byline">By <span id="By"><a href="http://www.ama-assn.org/amednews/site/bio.htm#o%27reilly">Kevin B. O'Reilly</a>,</span> <span id="Tag">amednews staff.</span> <i>Posted Feb. 4, 2013.</i></div><div id="Byline"><br /></div><div id="Btext1">During the winter holidays, a patient at Yale-New Haven  Hospital in Connecticut had a large pressure ulcer with an abscess. A  surgical intern made a note in the patient’s electronic health record  that said, “Patient needs drainage, may need OR.”</div><div id="Btext1"><br /></div>The problem? The same note appeared for several consecutive days,  even after a surgical team successfully drained the abscess. The intern  had copied and pasted the previous day’s note, but failed to  appropriately update it to reflect the fact that the drainage was done.  The note confused the consulting infectious disease team and nearly led  to an unneeded change in the patient’s antibiotic regimen.</blockquote><div id="Byline"><br /></div><div id="Byline">That's somewhat ironic<i>. </i> I performed my postdoc at Yale Center for Medical Informatics where we discussed, among other issues, potential drawbacks of badly-designed or implemented EHRs.   Unfortunately, I hear from people who've left that the Center is relatively marginalized these days with respect to influence.  (Actually, the marginalization goes way back; if they'd listened to us in the mid 1990's they might have avoided <a href="http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Insufficient%20IT%20management" target="_blank">this multimillion-dollar federal lawsuit for billing fraud</a>.)</div><div id="Byline"><br /></div><div id="Byline">Mr. O'Reilly continues:</div><div id="Byline"><br /></div><blockquote class="tr_bq">The practice of carelessly copying and pasting previous information,  often dubbed “sloppy and paste,” is on the decline at Yale-New Haven  Hospital but is widespread across medicine and can lead to mix-ups that  sometimes harm patients, research shows.<br /><br />“It’s especially problematic when you have multiple teams taking care  of the patient and we’re communicating through the chart, which happens  very often nowadays because physicians don’t see each other as often as  we used to,” said Dr. Horwitz [General internist Leora Horwitz, MD], assistant professor of medicine at Yale  University School of Medicine. “<b>We do rely on the chart in many cases,  and it can lead to genuine confusion.”</b></blockquote><br />When you rely on an information system and the information system contains incorrect information (for whatever reason), patients are put at risk.  That the systems are implemented without simple controls on copy-and-paste (such as permanently embedding substantive metadata in the output) is a significant flaw.<br /><br /><span style="mso-bidi-font-style: normal;"><span style="color: black; mso-bidi-font-size: 10.0pt;">From Sec. II of </span></span><i style="mso-bidi-font-style: normal;"><span style="color: black; mso-bidi-font-size: 10.0pt;">Aguilar v. Immigration and Customs Enforcement Div. of U.S. Dept. of Homeland Sec.</span></i><span style="color: black; mso-bidi-font-size: 10.0pt;"> 2008 WL 5062700 (S.D.N.Y. Nov. 21, 2008), available at <a href="http://jeffparmet.com/pdf/aguilar-v-immigration.pdf" target="_blank">this link</a>:</span><br /><br /><blockquote class="tr_bq"><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;">... Substantive metadata, also known as application metadata, is “created as a function of the application software used to create the document or file” and reflects substantive changes made by the user. Sedona Principles 2d Cmt. 12a; Md. Protocol 26. <b>This category of metadata reflects modifications to a document, such as prior edits or editorial comments</b>, and includes data that instructs the computer how to display the fonts and spacing in a document. Sedona Principles 2d Cmt. 12a. Substantive metadata is embedded in the document it describes and remains with the document when it is moved or copied. <i>Id</i></span></span></blockquote><br />Microsoft Word's "Track Changes" feature is an example of substantive metadata being displayed.<br /><br />The available stats on the phenomenon are of great concern: <br /><br /><blockquote class="tr_bq">... A study in February’s <i>Critical Care Medicine</i> found that copying and pasting is the rule in EHRs rather than the exception.<br /><br />Using a software program that can detect identical matching word  sequences, researchers examined the assessment-and-plan portions of more  than 2,000 progress notes for 135 patients created by 62 residents and  11 attending physicians working in a Cleveland medical intensive care  unit. For the residents, 82% of the notes contained 20% or more copied  text, while 74% of attending doctors’ notes also exceeded that rate of  copying and pasting.<br /><br />A similar study in the January-February 2010 issue of Journal of the  American Medical Informatics Assn. found a copy-and-paste rate of 78% in  sign-out notes generated by internal medicine residents. The rate of  copied text in progress notes was 54%, the study said.</blockquote><br /><div id="Byline">An example of physician embarrassment at relaying quite outdated information to a patient's family due to repeated note-copying was cited, and then a case of actual harm:</div><div id="Byline"><br /></div><blockquote class="tr_bq">... Other times, patients are harmed. In a July/August 2007 case study in <i>AHRQ WebM&M</i>,  an online patient safety journal, William Hersh, MD, described the case  of a 77-year-old woman hospitalized for diarrhea and dehydration after  chemotherapy.<br /><br />An intern noted that the patient would receive heparin to prevent  venous thromboembolism. The note was copied and pasted for four days in a  row and signed by a resident and an attending physician, who appeared  to believe the heparin had been ordered and administered. Ultimately,  the patient was discharged without ever receiving the preventive  medicine and two days later was rehospitalized and diagnosed with a  pulmonary embolism. Only then did physicians realize the patient never  got the correct prophylaxis.<br /><br />“The problem is getting worse now with the rise of EHRs,” said Dr.  Hersh, professor and chair of the Dept. of Medical Informatics and  Clinical Epidemiology at Oregon Health & Science University in  Portland.</blockquote><div id="Byline"><br /></div><div>The American Medical News article continues:</div><div></div><br /><blockquote class="tr_bq"><div>HHS OIG (Office of the Inspector General) announced that it plans to review multiple EHR notes for the same  patient by the same physician to see whether doctors are copying and  pasting the identical note from visit to visit. The practice is  sometimes called cloning and could be implicated in fraudulent coding  and billing practices. </div></blockquote><div><br /></div><div>That might serve to partially stem the process, but the HHS OIG's resources are not infinite.</div><div><br /></div><div>The article concludes:</div><div><br /></div><blockquote class="tr_bq"><div>John Halamka, MD, calls for a more radical fix.<br /><br />“The way we document in medicine has grown up over decades for  medical reasons, for billing, for medical-legal justification,” said Dr.  Halamka, chief information officer at Beth Israel Deaconess Medical  Center in Boston. “You wind up with 17 pages of replicated and  duplicated and challenging-to-read documentation. I propose we blow up  the way we do documentation altogether and replace it with a  Wikipedia-like structure.”<br /><br />Such an approach would allow physicians to edit the progress note  collaboratively, just as the popular open-source encyclopedia is  updated. Dr. Halamka hopes to pilot-test the idea within the next year. “With that concept, you wouldn’t ever really need to copy and paste,” he said.</div></blockquote><div></div><div><br />An interesting concept and experiment.  My questions:</div><div><br /></div><div><ul><li>Do we first rigorously investigate and understand the causes of the  copying, i.e., cryptic and difficult-to-use data entry methods that significantly slow clinicians down?   </li></ul><ul><li>Do we get informed consent from patients for the experiment? </li></ul><ul><li>If so, what do we tell them?  We are conducting an experiment in charting, risk unknown, to solve cheating and risks due to poorly-designed EMRs? </li></ul><ul><li>Would not simpler solutions (such as the embedded-metadata identifiers indicating text has been copied as I described above)  be important to implement first, <u>before</u> experimenting with medical documentation? </li></ul></div><div><b><br /></b></div><div>That said, I believe the practice - an unintended and potentially adverse side effect of a new information technology, HIT - must stop.  I think Mr. O'Reilly makes that point clear.  Read his article at the link above.</div><div><br /></div><div>-- SS</div><div></div>

American Medical News: Dangers of "EHR Sloppy and Paste"

An American Medical News ( amednews.com ) article by Kevin O'Reilly appeared entitled "EHRs: 'Sloppy and paste' endures des...

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