Author Archives: Connie Tohara

EHRs and the Perils of Copy and Paste

Guest blog by Connie Tohara, Director of Health Information, University of Utah Hospital

The national election is over, and the implications for healthcare are many.  However, rapid change is not just on the horizon—it has been a part of the everyday life of the HIM professional for longer than we care to remember.  Over the years, we have had the introduction of DRGs, MS-DRGs, APR-DRGs, RACs, MACs, MICs, and ICD-10, just to name a few.  The core product that we work with—the medical record—is changing as well.  We find ourselves in a transitional world.  We’re dealing with the additional requirements of hybrid records and scanning. Workflows must change and productivity is always taking a hit from one new problem or another.

The latest problem to raise its ugly head came with a letter to hospitals released on September 24th under the signatures of Kathleen Sebelius, Secretary of the Department of Health and Human Services (HHS), and Eric Holder, Jr., Attorney General for the U.S. Department of Justice.  In part, it states:

…there are troubling indications that some providers are using this [EHR] technology to game the system, possibly to obtain payments to which they are not entitled…. These indications include potential “cloning” of medical records in order to inflate what providers get paid…A patient’s care information must be verified individually to ensure accuracy:  it cannot be cut and pasted from a different record of the patient, which risks medical errors as well as overpayments. Continue reading