Health Information Management

Strategies to resolve and prevent unintended EHR system consequences

HIM-HIPAA Insider, April 7, 2014

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With the use of EHRs on the rise, so too is inappropriate use of EHR functionality. Many of these unintended consequences of EHR use are popping up on the radar of healthcare organizations and the federal government alike. The Office of Inspector General (OIG) recently took aim at EHR vulnerabilities in two reports. The first report, released in December 2013, addressed the lack of fraud safeguards in many EHRs, especially with respect to copy-paste functionality.

The second report, released in January, focused on the lack of integrity practices established by CMS and its contractors to address vulnerabilities in EHR technology. In this report, OIG revealed that few contractors review data in their EHRs differently from the way they review paper records. The report also revealed that some contractors could not identify copied language and over-documentation in EHRs.
"Copying and pasting documentation is a major issue because it is rampant throughout all specialties and because the providers like the ease of using it and are very resistant to giving that up," says Claire Norton, MD, physician advisor to care management HIM at Salem (Ore.) Hospital.
Dee Banet, RN, BSN, CCDS, CDIP, director of clinical documentation improvement at Norton Healthcare in Louisville, Ky., noticed a similar increase in the use of copy-paste functionality at her organization. "We quickly addressed it with an alert that signals all users upon entering the EHR that it is important to always review the clinical information to ensure it's applicable to the current medical condition of the patient," says Banet, who is also an Association of Clinical Documentation Improvement Specialists advisory board member ( The alert in Norton Healthcare's EHR system also reminds providers of the risks associated with improper use of system functionality, including quality-of-care issues and potential fraud.
Continue reading "Strategies to resolve and prevent unintended EHR system consequences" on the HCPro website. Subscribers to Medical Records Briefinghave free access to this article in the April issue.

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