The American Health Information Management Association has issued a position statement warning industry stakeholders about the risky practice of copy and pasting within an electronic health record.
"Use of the copy and paste functionality in EHRs can result in redundant, erroneous, and/or incomprehensible health record documentation," states the document. "Misuse of this functionality has the potential to result in or contribute to several overarching challenges, with implications for the quality and safety of patient care, medical-legal integrity of the health record, and fraud and abuse allegations."
While there are time-saving benefits to this practice, AHIMA advises that the "use of copy/paste functionality in EHRs should be permitted only in the presence of strong technical and administrative controls which include organizational policies and procedures, requirements for participation in user training and education, and ongoing monitoring." According to AHIMA, one study found that as many as 90 percent of physicians use copy and paste in their daily progress notes and a majority of narrative notes contain copied text.
However, copied and pasted notes may lead to a number of unintended consequences and AHIMA recommends that users of the copy/paste functionality "should weigh the efficiency and time savings benefits it provides against the potential for creating inaccurate, fraudulent, or unwieldy documentation."
AHIMA's position paper calls for the creation of best practices to be developed by private and public sector stakeholders. "AHIMA stands ready to leverage its experience and expertise and to lead a multi-stakeholder effort to identify, develop, and promote best practices regarding the copy and paste functionality in EHRs in order to help ensure high quality clinical documentation and health information integrity."
During a session at the 2013 AHIMA Conference in Atlanta, Michelle Mitcheff, physician services auditor at Indiana University Healths Southern Indiana Physicians practice, issued a call to action with HIM professionals among the leaders coming to the table with vendors to find a solution. Internally, you need to be in the know about what is happening and we need to be a catalyst of change.
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