Health Information Management

News: Safe use of copy/paste functionality

CDI Strategies, April 28, 2016

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Electronic health records may provide a number of benefits such as improving the continuity of care and making it easier to track and treat multiple co-morbid conditions, they also pose potential safety risks, according to the Toolkit for the Safe Use of Copy and Paste, published by the Partnership for Health IT Patient Safety earlier this year.
Among the risks the Toolkit listed included production of notes with internal inconsistencies, creating the need for more queries or work to determine if information is correct, erosion of confidence in the documentation, and the production of overwhelmingly long charts and notes (“note bloat”).
The toolkit’s authors included a hefty list of multi-disciplinary individuals from a wide-range of organizations including healthcare professional associations such as the American Medical Association and American Health Information Management Association, as well as healthcare IT providers such as Allscripts and McKession. The group recommended that organizations:
  • Provide a mechanism to make copy and paste material easily identifiable.
  • Ensure that the provenance of copy and paste material is readily available.
  • Ensure adequate staff training and education regarding the appropriate and safe use of copy and paste.
  • Ensure that copy and paste practices are regularly monitored, measured, and assessed.
“The recommendations are designed to allow the stakeholders the opportunity to identify ways to address the issues as the technology changes, recognizing that external forces, including regulations and requirements, may impact the recommendations in the future. The toolkit provides an opportunity and a challenge to all of the stakeholders to work on making copy and paste activities safer,” the toolkit states.
The ACDIS Advisory Board released a Position Paper regarding electronic health records and the role of the CDI specialist in October 2013. The paper points out that while “EHRs often promote copy and paste functionality as a time saver, copy/paste, used inappropriately, can lead to denials and/or allegations of fraud.”
It recommended that CDI specialists take note of copy/paste errors and bring them to the attention of an EHR or compliance professional and “if the problem persists, elevate it to an appropriate authority, such as a physician advisor, chief information officer, or chief medical officer, or an accreditation officer responsible for maintaining Joint Commission standards.”

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