The Federal Government is analyzing whether the use of the cut and paste option on computers is leading to billing fraud and documenting data not provided by the direct clinician involved.
Wikipedia states that in human-computer interaction, cut and paste and copy and paste are related commands that offer a user-interface interaction technique for transferring text, data, files or objects from a source to a destination. Most ubiquitously, users require the ability to cut and paste sections of plain text. The cut command removes the selected data from its original position, while the copy command creates a duplicate; in both cases the selected data is placed in a clipboard. The data in the clipboard is later inserted in the position where the paste command is issued.
The government feels the potential for driving up reimbursement codes is high as they are seeing a massive increase in billing charges at various institutions. The counter argument is that the EHR is allowing providers to charge a more realistic amount to cover the actual work. Hospitals receiving huge government monies for meaningful use are probably going to be the first groups targeted.
The fundamental problem is that the output (the final clinical document) that an EHR creates and/or generates look and sound like “cookie-cutter” templates where you can’t tell what was contemporaneously created versus obtained from other databases through cut and paste techniques. The output is in “computer ease” (language of computer generated script).
XpressCharts EHR is designed to be a proactive clinical tool that reflects the patient/provider interaction accurately. The use of chief complaint driven templates assemble data points that creates a clinician document. The clinician through voice activated technology (Dragon Medical), typing, and customizable macros can add depth and individualization to the documentation. This should pass the fraud test.