AHIMA cautions about using copy-and-paste

A new position statement from the American Health Information Management Association (AHIMA) warns industry stakeholders about the risky practice of copy and pasting within an EHR because that "can result in redundant, erroneous, and/or incomprehensible health record documentation."

Furthermore, "Misuse of this functionality has the potential to result in or contribute to several overarching challenges, with implications for the quality and safety of patient care, medical-legal integrity of the health record, and fraud and abuse allegations."

The position statement cites a study that found up to 90 percent of physicians use copy-and-paste in daily progress notes and a majority of narrative notes contain copied text.

To achieve the time-saving benefits of copy-and-paste functions, AHIMA says the practice "should be permitted only in the presence of strong technical and administrative controls which include organizational policies and procedures, requirements for participation in user training and education, and ongoing monitoring."

AHIMA cites several unintended consequences of copied and pasted notes, including interference with care team communication, inaccurate and outdated information and facilitation of inflated, duplicate or fraudulent claims.

AHIMA's position paper calls for the public and private sector to work together to implement its recommendations, which include the following:

• Develop best practice standards for monitoring compliance
• Design EHR systems that allows for configuration of copy-and-paste functions
• Address EHR usability issues
• Develop policies addressing proper use of copy-and-paste

Read the full position statement.