By Rachna Chaudhari and William Brady, June 01, 2012
As dermatologists increasingly adopt electronic health records (EHRs) and reap the rewards of having convenient access to more comprehensive clinical notes, they also face the temptation to use shortcuts with documentation to keep on schedule and be better able to manage their patient throughput. Dermatologists should be forewarned of the risks when using computer-automated or templated patient documentation, as this can often appear uniform and present a number of compliance issues especially if the medical documentation begins to resemble cloned notes.
What is a cloned electronic medical record?
The most meaningful and instructive definition of cloning comes from First Coast Services Options, a Medicare contractor, which considers documentation cloned “when each entry in the medical record for a [patient] is worded exactly the same, like, or similar to the previous entryand occurs when medical documentation is exactly the same from [patient to patient]it would not be expected that every patient had the exact same problem, symptoms, and required the exact same treatment.” Generally, chart cloning can occur from one patient’s notes to the next using the same template shortcuts, or by continually using the same patient note for different visits. The bottom line is that any act of copying and pasting or using templates to create the same documentation note for multiple patients would qualify as cloning and bring unwanted attention and unpleasant consequences.[pagebreak]
What are the dangers of cloned notes?
EHRs and electronic prescribing programs can deliver new safeguards and benefits with respect to patient safety and medical errors. However, they have also opened the door to new liability risks and compliance concerns. Many EHRs automatically calculate the codes for a visit based on the physician’s medical documentation; if the documentation is simply being copied and pasted for every visit or being generated through a template, there is a risk for up-coding. The Office of the Inspector General’s 2011 Work Plan noted this as a concern and stated that OIG planned “to identify electronic health records (EHR) documentation practices associated with potentially improper payments.” The OIG’s 2012 Work Plan continues to identify cloned notes as a priority for the second year in a row.
Additionally, several Medicare Administrative Contractors (MAC) are beginning to formulate policies on cloned notes to address this issue (see sidebar), and private payers are also monitoring and expected to develop safeguards against this trend.
Besides improper payments, cloned notes also open practices to malpractice concerns. Patients who are seen continually could have conflicting medical notes if a physician chooses to copy and paste only what is relevant from the last visit. For example, a physician could import a standard documentation template for an established visit with a psoriasis patient, however if that patient was previously diagnosed with melanoma, that information would be missing from the note. Another common mistake is to accidently copy and paste information not relevant to a patient’s medical note. An adult smoker’s documentation on acne could be copied and pasted into a child’s chart, thus labeling that patient as a smoker. Both of these instances would be easily flagged by a plaintiff’s attorney in a malpractice case.[pagebreak]
How should dermatologists address cloned notes?
The single most important thing dermatologists should do to avoid cloned notes is review their documentation for every visit. They should also enter unique and relevant information if applicable as free text if they are using a template within the EHR. Remember that the physician’s signature is attached to every medical note, and the physician is individually responsible for the bill. Practices should also perform audits on a regular basis to identify patterns of cloned notes. As both public and private payers continue to monitor this ever-present risk, dermatology practices are advised to develop a compliance program and train all members of the practice, including physicians and clinical staff. This compliance plan should focus on appropriate patient care enhanced by accurate documentation and correct billing procedures to avoid both legal and financial risks. Cloning may harm patients’ health and put your practice at risk of charges of abuse and fraud.[pagebreak]
Steps your office should take to address cloned notes:
- 1. Be aware of the pitfalls that EHRs can produce, especially when performing evaluation and management (E/M) documentation.
- 2. Be careful to pay attention when using point-and-click templates to help with documentation.
- 3. Limit your dependence on copying and pasting and rely on documentation in your own words.
- 4. Repeatedly review your notes for accuracy and medical necessity to ensure coherence and agreement before closing them.
- 5. Avoid the habit of generating “too much information” for purposes of documenting higher level charges, and focus instead on clinically pertinent information that reflects medical necessity.
- 6. Do your own work by documenting your own notes — don’t clone from others.
- 7. Make sure to discuss your concerns with your staff — including coding and billing staff and your office manager — to consider troubleshooting auto-populate fields and canned verbiage that may pop up in your EHR software.
- 8. Develop a compliance plan for your practice to mitigate against unexpected audit risks.
- 9. Review any audit or documentation deficiencies your practice may experience by routinely performing self-audits as part of your compliance efforts.