AHIMA Issues Statement on Copy-and-Paste Concerns

The use of the “copy and paste” functionality in EHRs should only be permitted in the presence of strong technical and administrative controls, according to a position statement released by AHIMA. 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.

In its position statement, AHIMA calls for government and private organizations to work together and implement 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,” says AHIMA CEO Lynne Thomas Gordon, MBA, RHIA, CAE, FACHE, FAHIMA. “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.”

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.
To ensure appropriate use of the copy/paste feature, AHIMA recommends several steps, including the following:

• Forming collaborations among health care providers, health information and technology professionals, federal agencies, and system developers, among others, to develop best practice standards for monitoring compliance and organizing policies and procedures for clinical documentation.
• Sharing responsibility for ensuring that EHR systems support compliant clinical documentation and related billing and coding practices.
• Designing EHR systems so health care 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 health care providers to develop policies and procedures to assure compliance with governmental, regulatory, and industry standards.

To view the full position statement, visit the AHIMA website at http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_050621.pdf.

Source: AHIMA