AHIMA Position Statement Warns of EHR ‘Copy and Paste’ Dangers
The time-saving but often problematic practice of copy and pasting within an electronic health record (EHR) demands the creation of best practices developed by private and public sector stakeholders, a new AHIMA position paper recommends.
The copy and paste functionality that exists in many EHRs—also known as “cloning,” “carrying forward,” and “identical documentation”—should only be allowed in settings where there are strong technical and administrative controls, “which include organizational policies and procedures, requirements for participation in user training and education, and ongoing monitoring,” the position paper states.
Clinician use of copy and paste functionality in EHRs is widespread, in part because it saves users time by reproducing lengthy progress notes and narrative patient data. This functionality can be used within the same person’s chart as well as across multiple patients’ charts. According to research cited in the position statement, as many as 90 percent of physicians use copy and paste in their documentation.
However, the practice can lead to errors such as:
- Inaccurate or outdated information
- Redundant information
- An inability to identify when the documentation was first created
- Unnecessarily lengthy progress notes
- The propagation of false information
The practice of copy and paste is also often used to perpetrate fraud.
“A desired outcome of EHR implementation is to increase the quantity and utility of data available to clinicians about each patient,” the paper states. “While increased availability of this information is useful for informed clinical decision-making, too much information can lead to difficulties in navigation and synthesis.”
In its position statement, AHIMA aimed its recommendations to four distinct groups—industry stakeholders, healthcare provider organizations, EHR system developers, and the public sector.
Click here to read the full position statement in AHIMA’s HIM Body of Knowledge.