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EMR Cloning: A Bad Habit

Convenient computer function may prompt patient care concerns, payment denials and legal questions By Juan P. Cueva, MD

The widespread adoption of electronic medical records (EMRs) in hospitals has resulted in a shift from the traditional clinical narrative writing style to an unintended reliance on the computer function known as copy and paste. It is also referred to as a save as macro, or carry forward, or most descriptively—EMR cloning.

Hospital attendings may have observed how medical residents and younger hospitalists, who grew up with computers, have assumed the liberty of writing and organizing their electronic hospital notes with minimal direction and no clear-cut hospital or professional standards.

The EMR function called copy and paste allows physicians to easily incorporate lab tests, round the clock vitals, and every conceivable report in a single progress note. While the feature is handy, it creates risks for the patient, hospital and physician.

However, these risks can be mitigated if physicians develop a writing style, tailored to the EMR, which makes use of the long-established hospital narrative. This narrative style is essentially storytelling that relays the particulars of the patient’s illness, with events sequenced chronologically, along with appropriately inserted clinical commentary and discussion of treatments.

In contrast, when a physician relies on copy and paste in EMR charting, vast amounts of clinical data and whole text from previous notes or the initial history and physical, regardless of author, or even the original patient, can end up being pasted into the new note. EMR cloning quickly makes yesterday’s note into today’s note but the story of the patient is muddled with a deluge of clinical information.

Worse yet, EMR cloning has resulted in Medicare and other insurance companies denying payments, thus inviting case review and new legal liabilities. Recent studies have also established EMR cloning as a potential factor in poor patient outcomes, such as when the cloning of glucose labs in hospitalized diabetics becomes harmful.

Of course, as a platform for hospital communication, EHRs have advantages, such as legibility, simultaneous access to records, and endless data storage space. Although multi-page EMR notes can be assimilated by the reader, the lack of narrative order often impedes clarity. What is now being diminished, or even eliminated, is the 100-year-old tradition of hospital narrative writing that tells the story of the patient’s condition in a manner that is easy to understand and remember. Even longtime physicians have abandoned the clinical narrative and simply click a line or two in the EMR.

While EMR cloning may appear to save time, the U.S. Office of the Inspector General (OIG) is currently reviewing duplication standards in hospital charting and has stated that the use of duplicate entries “may be associated with improper payments.” Medicare defines cloning as multiple entries in a patient chart that are identical or similar to other entries in the same chart. The independent Medicare administrative contractor (MAC) who reviews charts for appropriateness of service has been directed by the Centers for Medicare and Medicare Services (CMS) to identify “suspected fraud, including inappropriate copying of health information” under the Benefit Integrity/Medical Review Determinations mandate.

MACs have started to deny payments on the grounds that cloning is a “misrepresentation of the medical necessity required for services rendered.” This is an absence of explicit, individual information. One MAC contractor has established policies for its reviewer to assure that medical necessity of hospital services includes documentation demonstrating that physician notes are different and not merely a copy of the initial history and physical entry. The Center for Government Services (CGS) states, “For Medicare, the medical necessity of a service is the overarching criterion for payment,” but necessity is considered fraudulent if cloning of past medical services, lab and x-ray results, and medical notes from previous days, are simply reinserted into a new day’s progress note to justify need.”

Clinical Plagiarism?
One journal article on EMR cloning went so far as to declare that physicians who copy and paste text from other physicians’ notes may be committing “clinical plagiarism” since they are documenting work that they did not perform. The article points out that, “from an auditor’s standpoint, you don’t know how much work was actually done.”

Reed Gelzer, MD, MPH, co-founder of the Advocates for Documentation Integrity and Compliance, points out that, “Overwriting (cloning) misrepresents who provided the service, which could alter the amount billed. In addition, by submitting cloned documents for billing you are committing (insurance) fraud.”

Another concern of EMR cloning in academic hospitals is that some residents’ charting may lack daily or updated physical examinations and patient assessments. The EMR's benefit as a platform for improved communication among medical team members is diminished when cloning generates redundancy and doubts exists about the most current updates. With increased patient workloads for attending, residents, and nurses, the use of additional health care providers such as advanced practice nurses is facilitated by succinct clinical information rather than long, cloned notes.

Undoubtedly, the characteristics of the EMR discourage reading. The electronic chart is twice as far from the reader’s eyes with much smaller type, so it appears physicians are not reading each other’s notes. This is an inherent defect of the EMR that further discourages reading all the cloned data and text.

When my hospital mandated EMR use, my first computer notes—with their tiny type, long sentences, and no paragraphs—appeared stark on the electronic page. My initial response was to bulk up my note, to give it more clinical gravitas with additional labs, vitals, and other reports. But it was easier to just add, “Discussed with resident and agree with above,” and electronically sign the resident’s note and make it my note as the physician of record.

Eventually, I stopped co-signing cloned notes and developed my own electronic charting style that briefly documented my own clinical assessment, plan of care and discussions with the family. My eureka moment came when I realized that we physicians still discuss the patient’s illness, treatments and diagnostics as a story, telling the relevant history of sickness over time. If physicians still speak to each other in the language of narrative, why not write this way as well?

The hospital EMR does enable the use of the  so-called free text notes that allow the physician to write without restraint, without fill-in-the-blanks or click-the-choices. The EMR permits the use of larger, easier-to-read type. Certainly, short, multiple, double-spaced mini-paragraphs are much easier to compose and read. Other time-saving techniques include the use of the complex cumulative sentence that splices together sentences and phrases, as well as the liberal use of conjunctions and commas. This can create highly dense clauses and modifying phrases that eliminate unnecessary words and make for more concise writing.

Since EMRs are still in their infancy, physicians on relevant hospital committees should lead the development of standards for copy and paste, limiting indiscriminate cloning, and encouraging new forms of documentation within the EMR. Physicians can develop their own clinical narrative writing style based on the traditional narrative and tailor it for the computer screen. Although EMR cloning is tempting, using it wisely will improve patient safety and assist in staying compliant with insurance and government regulations.

Dr. Cueva is a practicing pediatrician and a member of the Pediatric Performance Improvement Committee at Advocate Children’s Hospital in Oak Lawn. He can be reached at drjcueva@att.com.

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