Tuesday, October 9, 2012

HHS and DOJ Issue Joint Letter on Cloning of Medical Records

On September 24, 2012, Secretary Katherine Sebelius of the Dept. of Health and Human Services, and Eric Holder, Attorney General, of the Department of Justice, issued a joint letter to several health care associations, including the American Hospital Association and Federation of American Hospitals. You can view a copy of the letter on HCC University, on our Tools page.

Although the letter applauds the widespread adoption of EHRs, it notes that there are indications that some providers are using them to clone records and to game the system.  The letter points out that this type of false is not only dangerous to the patient, but also illegal. 

The letter notes that CMS is stepping up its medical record review activities to identify these issues, and that the DOJ, FBI and other law enforcement are monitoring these issues and will take action when warranted.

So--how do CMS, the DOJ and others identify cloned medical records?   Cloned records are often very obvious.  Although they may occur in handwritten records, it is most often found in EMRs with cut and paste and template functionality. 

Although templates are not inherently bad, auto-populating them indiscriminately with information can lead to obviously cloned records. While some things may not change significantly from visit to visit (for example, the bulk of the patient's history may remain the same), a patient's condition is rarely, if ever, static.  A patient's interim history, vital signs, symptoms and treatment are almost never exactly the same. Copying and pasting these components leads to inaccurate medical records.

Another area where cloning becomes obvious is in the assessment.  Often, previously treated or self-limiting diseases remain in the assessment for months or even years.  We've seen charts where a diagnosis of "acute sinusitis" continued on for over a year, with no treatment after the initial date of service where it appeared.

It's important to remember that once one part of the medical record is obviously wrong, and auditor is likely to discount the record in its entirety, since it's impossible to tell what is and isn't accurate.

Clinicians using EMR should use templates wisely, and cut and paste functionality very sparingly.  All information in the chart should accurately reflect the patient's complaints, conditions, and treatments on the current date of service.

No comments:

Post a Comment