The Chicago-based American Health Information Management Association (AHIMA) has issued a statement saying that the use of the “copy and paste” functionality in electronic health records (EHRs) should only be permitted in the presence of strong technical and administrative controls.
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, the statement read. AHIMA also called 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,” AHIMA CEO Lynne Thomas Gordon said in the 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.”
To ensure appropriate use of the copy/paste feature, AHIMA recommends several steps, including:
• Forming collaborations among healthcare 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 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 IT (ONC) 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 assure compliance with governmental, regulatory and industry standards.
“All healthcare organizations have a responsibility to ensure the integrity of EHRs,” Thomas Gordon said. “As the premier association for health information management, AHIMA stands ready to lead the effort to ensure high-quality clinical documentation and health record integrity on issues such as the appropriate use of copy and paste.”