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Reduce the Risk of EHR Cloning at Your Retina Clinic

Medical Documentation

Sep 15, 2023

Apr 15, 2025

Written By Elizabeth Cifers

Written By

Electronic Health Records (EHR) were introduced to minimize medical errors, enhance healthcare quality, and cut costs linked to inefficiencies, errors, and incomplete data.¹

While many retina clinics transitioned from paper to EHRs, others hesitated. Despite the varied opinions, EHRs have undeniable benefits, especially in retina care.  

Some of these benefits include:

  • Immediate access to patient data, even when the retina physician is out of the office.
  • Easily readable medical records.
  • Warnings for patient allergies.
  • The convenience of electronic prescriptions.
  • Efficient management of medical claims.²

But it's crucial to remember that EHRs, despite their digital nature, are still created by human hands—and humans, inevitably, make errors—like EHR copy/paste or pull forward, also known as cloned documentation.

EHR Cloning and Other Medical Documentation Weak Points

In early 2014, Daniel R. Levinson, the Department of Health and Human Services Inspector General, released a revealing study named “CMS and Its Contractors Have Adopted Few Program Integrity Practices to Address Vulnerabilities in EHRs”.³

The study shed light on several documentation-related vulnerabilities in medical records. These included challenges in pinpointing the actual author of an entry, instances of exaggerated medical documentation, and potential misrepresentation of services provided.  

Two main issues emerged:

  1. Cloned documentation: Often seen as ‘copy-pasting’ or ‘pulling forward,’ it involves replicating past patient notes for current visits.

This becomes problematic when the information isn’t updated to reflect the new visit, leading to discrepancies and undermining the trustworthiness of the whole medical record.

  1. Template Overuse: EHR systems often have templates with pre-set statements, making over-documenting easy. Misuse can lead to medical records that don’t reflect the services provided.

Examples of EHR Cloning and Other Inconsistencies in Retina Clinic Documentation

Example 1: A Visual Inconsistency

Visual Acuity:

  • OD: 20/50
  • OS: No-Light-Perception (NLP)

Confrontational Visual Fields:

  • OD: Full to finger counting
  • OS: Full to finger counting

Issue: While the left eye (OS) is recorded as having no light perception, it’s simultaneously described as being able to count fingers. Which is it? This discrepancy could be the result of EHR cloning at the retina clinic.

Example 2: A Hole in the Story

Periphery:

  • Both OD and OS: Flat with no holes detected.

Impression:

  • OS: Indicates the presence of a macular hole.

Issue: The initial exam finds no holes, but the impression notes one. Which is accurate? Cloned documentation could be to blame for this mismatch.

Example 3: Edema or No Edema; That Is the Question

Macula:

  • Both OD and OS: No signs of macular edema.

Impression:

  • OD: Severe edema observed and confirmed.

Issue: The exam suggests no edema, but the impression disagrees. Which can we trust? EHR cloning can result in untrustworthy documentation at your retina practice.

Example 4: Mixed Signals on Edema

Macula:

  • OD: Shows improved diabetic edema.
  • OS: Indicates no diabetic edema.

OCT Interpretation:

  • Both OD and OS: Indicate worsening edema.

Impression:

  • OD: No edema detected.
  • OS: Suggests increasing edema.

Issue: The medical records present conflicting information about the presence and severity of edema in both eyes. Which statement is reality?

Such inconsistencies pose genuine concerns about the reliability of EHR data at retina clinics and emphasize the importance of thoroughness and accuracy in medical documentation.

Retina specialist cloning an EHR at his clinic

Issues with Medical Documentation Integrity in EHRs

The previous examples underscore a looming issue: the potential compromise of medical documentation integrity.  

When information from templates or prior exams is inaccurately carried forward, the result is a perpetuated discrepancy, leading to the phenomenon known as EHR cloning.

The Implications of EHR Cloning for Your Retina Clinic

  • Repetitive Patient Records: Cloned documentation can result in a situation where one retina patient's medical record mirrors every other visit within their file. It looks as though the patient's conditions, findings, or complaints never change.
  • Duplicative Patient Profiles: EHR cloning also risks creating an environment where every retina patient's medical record looks strikingly similar to the next. This duplication, especially when automated templates are over-relied upon, can make it nearly impossible to distinguish between individual patient records unless one checks the patient's name.

The Need for Diligence in Medical Documentation

The use of pull-forward or copy-paste functionalities in EHRs requires great care. To maintain the authenticity and accuracy of medical records:

  • Each individual interacting with the record should thoroughly review and ensure the details accurately represent the current visit.
  • Retina staff should be trained to recognize and correct potential inaccuracies from over-reliance on templates or EHR cloning practices.

The Risk of “Code Creep” for Your Retina Clinic

Another significant concern linked with EHR cloning is the emergence of “code creep.” This refers to the possible escalation in medical billing codes—potentially leading to “upcoding.” Upcoding occurs in retina practices when physicians bill using a Current Procedural Terminology (CPT⁴) code that represents a more complex or expensive service than was actually provided.⁵

The fallout:

  • Financially: It results in inflated medical billing, which could lead to serious legal repercussions (the last thing your retina practice needs).
  • Ethically: Upcoding is a misrepresentation of the services rendered.

In cases where medical documentation doesn’t validate the services claimed, the payments need to be returned. Retina providers should ensure their medical billing practices align with the services rendered to maintain integrity in patient care and financial practices.

Addressing EHR Cloning and Upcoding

To navigate the challenges of EHR cloning and possible upcoding, here’s a structured approach to safeguard transparency, accuracy, and compliance at your retina clinic:

Educate Your Retina Team

  • Coding and Documentation Training: Provide robust training sessions to familiarize the team with the correct coding and documentation practices—including exercising proper care when using EHR cloning features.
  • Understanding Consequences: Make sure everyone knows the legal and ethical ramifications of improper medical documentation and coding.

Streamline Your Chart Documentation

  • Template Evaluation: Periodically review and potentially adjust EHR templates and auto-population settings to minimize the chances of misrepresentation at your retina clinic.
  • In-depth Clinical Data: Set up your EHR system to allow for comprehensive clinical information capture without defaulting to generalized statements.

Conduct Internal Chart Audits at Your Retina Clinic

  • Compliance Review: As part of your retina clinic's internal compliance program, consistently review coding and documentation practices.
  • Addressing Systemic Issues: Should you uncover extensive or recurring issues resulting from cloned documentation or something else, consider seeking counsel, especially if re-payments are possible.

Conduct External Chart Audits, Too

EHR Cloning: Final Thoughts

While EHR systems have revolutionized healthcare, streamlining operations and enhancing efficiency, they are not without potential pitfalls. The key is to harness their benefits for your retina clinic without succumbing to common drawbacks like EHR cloning or upcoding.

Being forward-thinking, proactive, and vigilant in medical documentation will protect your retina practice from unintentional errors. Safeguarding processes to confirm that patient records and claims submitted genuinely mirror the care provided is a must.

What Next for Your Retina Clinic?

Are you wondering if cloned documentation is putting your retina practice at risk of an audit?  

Allow me to guide you.  

I am adept at identifying your audit vulnerabilities—including those created by EHR cloning—and with my expertise, we can devise a comprehensive plan to correct issues or concerns, easing the anxiety in your retina practice from potential audits.

Why am I the right fit?  

With a proven track record and a strategic approach, I'm known for fortifying retina practices against audit risks.

Don't wait for the CMS or another payer to come knocking. Audit-proof your retina practice today; book a free consultation call here.


References

1https://www.govinfo.gov/content/pkg/WCPD-2004-05-03/pdf/WCPD-2004-05-03-Pg702.pdf. Accessed August 29, 2021.
2https://www.healthit.gov/topic/health-it-and-health-information-exchange-basics/benefits-ehrs. Accessed August 29, 2021.
3https://oig.hhs.gov/oei/reports/oei-01-11-00570.pdf. Accessed August 29, 2021.
4CPT is a registered trademark of the American Medical Association. CPT copyright American Medical Association. All rights reserved.
5https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Downloads/docmatters-ehr-providerfactsheet.pdf. Accessed August 29, 2021.

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