AHIMA urges action on cut-and-paste
March 31, 2014 in Medical Technology
The American Health Information Management Association, the organization made up of professionals who manage healthcare information, is urging controls on the copy-and-paste functionality in electronic health record systems. The use of copy-and-paste should be permitted only when such “strong technology and administrative controls,” are in place, the organization wrote in a position statement.
“Users of copy and paste – reproducing text or other data from one source to another destination – should weigh the efficiency against the potential risk for creating inaccurate, fraudulent or unwieldy documentation,” wrote AHIMA, which represents more than 72,000 health information management and health informatics professionals.
[See also: EHR copy and paste? Better think twice.]
In its statement, AHIMA called on government and private organizations to work together in implementing its recommendations to address recent concern about the potential for fraud and inaccuracy in EHRs.
“Reliable and accurate EHRs are essential to empowering patients and physicians with real- time information to improve quality of care,” AHIMA CEO Lynne Thomas Gordon, said in a statement. “AHIMA is sharing its expertise to identify, develop and promote best practices for the copy and paste functionality in EHRs to ensure high-quality clinical documentation and health information integrity.”
[See also: ‘Note bloat’ putting patients at risk.]
Using copy and paste inappropriately can result in redundancies and errors. Misuse has implications for the quality and safety of patient care, as well as potential for fraud and abuse, Thomas Gordon added.
AHIMA recommends several steps, including:
- Forming collaborations among healthcare providers, health information and technology professionals, federal agencies and system developers to develop best practice standards for monitoring compliance and organizing policies and procedures for clinical documentation.
- Sharing responsibility for ensuring EHR systems support compliant clinical documentation and related billing and coding practices.
- Designing EHR systems so healthcare providers can configure the use of the copy and paste functionality, including recording copy and paste user actions, audit capabilities and reporting.
- Having agencies such as the Office of the National Coordinator for Health Information Technology and the National Institute of Standards and Technology continue to address EHR usability issues, with an increased focus on documentation capture processes.
- Requiring healthcare providers to develop policies and procedures to ensure compliance with governmental, regulatory and industry standards.
“All healthcare organizations have a responsibility to ensure the integrity of EHRs,” Thomas Gordon said, adding that AHIMA stands ready to lead the effort.