Copy-paste of lifestyle counseling documentation and provider billing

Abstract

Objective: Text fragments are commonly copied between notes in electronic medical records and concerns have repeatedly been raised about the inappropriate use of the copy-and-paste feature to duplicate information across provider notes. It has been demonstrated that copied documentation of lifestyle counseling, unlike original records, is not associated with improvements in glycemic control in patients with diabetes, and therefore may not be a reliable representation of care provided. We sought to determine if there was evidence that copied documentation of lifestyle counseling is used by physicians to justify higher encounter and management charges. We also evaluated the relationship between frequencies of encounters with copied, distinct or no documented counseling with time to achievement of target hemoglobin A1c level. Methods: We conducted a retrospective cohort study of 16,006 patients diagnosed with diabetes mellitus who were followed by primary care physicians affiliated with Brigham and Women's Hospital and Massachusetts General Hospital for a minimum of two years between 01/01/2000 and 12/13/2009. An individual encounter with a provider in a primary care practice in the setting of an elevated hemoglobin A1c measurement served as the unit of analysis for the evaluation of the relationship between copied counseling and encounter and management charge level. To test the association, an ordered multinomial logistic regression model was constructed using GLIMMIX procedure to correct for clustering within individual providers and patients and adjusted for patient and treatment characteristics. Periods with hemoglobin A1c measurements above the treatment target served as the unit of analysis for the evaluation of the relationship between copied lifestyle counseling and glycemic control. Marginal Cox proportional-hazards model for clustered data and adjusted for patient and treatment characteristics was utilized to estimate the relationship. [TRUNCATED]