Healthcare practitioners enjoy the ease and productivity that EHR services provide for their medical practice. Yet, health professionals must take care to properly use and document their patient encounters. Otherwise, the ease and functionality of an EHR or EMR can actually expose a clinician to some unforeseen legal liabilities. This healthcare trend has been increasing in recent years and will likely only continue to rise, unless careful considering is given to how EHR services/systems are used. One of the primary reasons for using an electronic health record was to ensure and expand the quality of care received by patients.
Potential legal liabilities arise when healthcare practitioners use their EHR/EMR to “copy and paste” patient data from one note to other notes. When information like this is simply “moved forward” from one note to the next, it gives the appearance that the same medical service was provided on multiple occasions. In this circumstance, a healthcare practitioner could be accused of improper billing and even fraud. The Office of the Inspector General of the Department of Health and Human Services stated that “Because many hospitals cannot customize the copy-paste feature in EHR technology, the need for policies to govern its use is elevated. The copy-paste feature can be used appropriately and enhance efficiency; however, this feature also poses risks.”
The Centers for Medicare and Medicaid have also warned healthcare professionals about the practice of copying & pasting or cloning of EHR data. “Cloning—This practice involves copying and pasting previously recorded information from a prior note into a new note, and it is a problem in healthcare institutions that are not broadly addressed.” The CMS continues by stating that “the medical record must contain documentation showing the differences and the needs of the patient for each visit or encounter. Simply changing the date on the EHR without reflecting what occurred during the actual visit is not acceptable.”
These legal liability issues also create a number of malpractice claims. The issue of improper EHR usage and malpractice often appear as failures of clinical decision supports by health professionals. These alleged failures are sometimes connected to the mere act of copying and pasting a patient’s progress report. Claims of improper usage of EHR services can occur in nearly any medical setting. Over the past few years, EHR and EMR-related malpractice claims have occurred in physician offices, ambulatory surgery centers, hospital clinics and emergency departments.
ABCS RCM strongly believes that the benefits that EMR and EHR systems offer, outweigh the legal liability and malpractice risk. If proper procedures and regulations are established and followed, EHR services promise to improve the level of services that a patient can receive. Most new medical technologies require up-to-date and forward-looking policies in order to deliver true value to the healthcare community. The same rule applies to modern EHR services, which will only become more common, sophisticated and better.
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