To Criticize EHR Cut, Paste is to Criticize Template-based Charting

December 16, 2013

Look no further than a recent report on copy-paste functions for proof that HHS does not understand EHRs. Here's where they are missing the mark.

The Office of the Inspector General (OIG) of HHS has released a report entitled "Not All Recommended Fraud Safeguards Have Been Implemented in  Hospital EHR Technology."  The report identifies a number of areas that the OIG considers to be related to fraud. The biggest criticism is directed at the availability and use of "copy-paste" functions.

The following statement by the OIG proves that HHS does not understand EHR: "Copy-paste is most useful with facilitating data entry of physicians’ progress notes; however, few hospitals had fully implemented that function." If you have been following these articles, you know that creating an informative progress note, regardless of how it is done, is not a data entry task. HHS clearly views EHR primarily as a data collection device, not one intended to facilitate the creation of a high-quality medical record. Hospitals have gotten the message and have concentrated on data collection. The OIG also says that "Only four percent of hospitals ... had fully implemented electronic progress notes." In other words, an EHR installation that does not implement a charting function can still be considered "fully functional." This supports my assertion that any EHR, that treats charting as optional or an afterthought, is not a health record at all.

Copy-paste is the only fraud-related area identified by the OIG in which the onus falls on physicians to behave responsibly. The OIG laments that, "Even the hospitals that had policies seemed to have limited control over the use of the copy-paste feature." The OIG would apparently prefer that EHRs not allow copy-paste at all, but seem reconciled to the fact that it is not possible to completely block the function on a system-wide basis. Using hospital policy to enforce desired behavior is a poor substitute for having a staff that is willing and able to do what is right without prompting, monitoring, and nagging.

Anyone that has attempted to use policy to alter physician behavior knows that it is singularly ineffective. For some physicians (including you, of course) honesty and transparency are instinctive. Others have defective moral compasses and these traits seem to be optional. They may behave "properly" when it is to their advantage to do so but generally do what is most convenient.

The Take-Home Message

"Cut and paste" is not merely some aberrant behavior to be stamped out, it forms the core of dictation and template-based charting, so common in certified EHRs. Templates typically present a prototypical history and physical and depend on the examiner to add and remove elements until the end-product reflects the current situation, a process that can be as time-consuming as starting with a blank page.

The process of using templates has built-in sources of error. Even a diligent practitioner will make mistakes during the process of pruning and augmenting a note that began life as a template. We are told that "cut and paste" is bad. It certainly can be, in unethical or overworked hands, but a template is merely another source from which material is "copied" and then "pasted" to become the starting point of a new note.

I don't see a difference between pasting content from a prior note and beginning a charting session with a template. The only difference is the source of the pasted material. In the first case, material comes from a real patient and might actually be relevant. The template, on the other hand, originates in some fantasy world. Every template presents a textbook case of x, y, or z and is never correct until revised. Until revised, it is wrong and, in the OIG's opinion, fraudulent. To worry about cut and paste, and I do, is to condemn not only the act of uncritical copying from other chart entries, it is to condemn template-based systems in general for the way in which they facilitate the commission of intellectual fraud.

To allow template-based EHRs to be certified is to fail to grasp this basic concept. One might characterize the OIG's criticism of cut and paste as follows: Practitioners must use a certified EHR. Many certified EHRs are template-based. Using a template as the starting point for a note is no different, conceptually, from copying and pasting material from any other source. Copying and pasting are considered either to be fraud or to create a high risk of fraud. So, the OIG is criticizing the underpinnings of the very systems, the use of which has been mandated by HHS. HHS imposes one kind of penalty for avoiding this quagmire and a different one for stepping into it.

By expressing concern over copy-paste behavior, the OIG is, appropriately but unwittingly, calling into question the ability of today's certified EHRs to perform as expected but, even if a new paradigm gave rise to a new generation of EHR that revolved around the medical record, the potential for intellectual fraud would still exist, although the incentives to act inappropriately might be reduced.

The only true safeguard against fraud, whether financial or intellectual, is not more regulation in the form of "tougher" policies and more intensive auditing. It is to create an environment that selects for and nurtures practitioners with high ethical standards and excellent skills. An environment where transparency is rewarded, not punished. An environment in which every patient needs what they get and gets what they need, remembering that what they need most is the time and attention of a caring practitioner. That means paying doctors, not for the nature of a patient's ailment but for the skill, time and attention that they devote to providing care.