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AHIMA: EHR cloning needs tight controls and workflow limits

By Jennifer Bresnick

- The American Health Information Management Association (AHIMA) has published a strongly worded issue brief decrying the rampant use of cloning, or copying and pasting information, within the EHR.  While many providers use the quick trick as a timesaving measure, the risk of creating significant errors or outdated documentation often outweighs the benefits, and providers should be careful to institute “strong technical and administrative controls” to prevent misuse of available EHR tools.

“The copy and paste function provides the ability to re-use all or parts of detailed narrative information and is seen by physicians and EHR system users as a valuable and time saving tool,” the brief explains. “This duplication of notes can be conducted within a single patient’s record or across multiple patients’ records. Copying and pasting of healthcare documentation from previous medical record entries is not a new phenomenon and seems extremely common—indeed, prevalent—with at least one study finding that as many as 90 percent of physicians use this functionality in daily progress notes and that a majority of narrative notes contain copied text.”

But this practice can lead to seriously detrimental unintended consequences, including accidentally fraudulent documentation, the inclusion of outdated information from previous notes, redundant information, and confusion over who has authored the most current note for coordination of care.  The implications to patient safety and communication among staff members are significant, the brief stresses, and may even lead to improperly inflated Medicare claims that could result in CMS audits.

In order to avoid the downside of EHR cloning, organizations should develop clear guidelines for when copying and pasting is acceptable and when it is not.  Industry stakeholders should collaborate to develop best practices for using the feature, including alternatives to the practice that are similarly or more efficient.  Healthcare organizations should make a point to monitor the practice among staff members to ensure that standards are achieved and maintained.

“The knowledge, skills, and expertise possessed by HIM professionals should be leveraged by policy makers, healthcare providers, and EHR system developers to provide practical solutions to information integrity, management, and governance challenges, including on EHR functionalities such as copy/paste,” the brief adds.

Meanwhile, EHR developers should design their systems to allow users to configure the use of copy and paste settings to meet their own data standards and governance plans.  Public agencies like the ONC and NIST may wish to consider including copy/paste functionality in their certification criteria in order to promote widespread standards, and CMS should promote education around the issue to help providers understand the problems of inappropriate cloning.

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