AHIMA Releases Position Statement on the Use of Copy-And-Paste Functions in Electronic Health Records

The American Health Information Management Association (AHIMA) recently released its position statement on the use of copy-and-paste functionality in electronic health records (EHR).  AHIMA concluded that the use of copy-and-paste functions in EHRs can result in “redundant, erroneous, and/or incomprehensible health record documentation” and that misuse of copy-and-paste can contribute to issues related to quality of care, patient safety, document integrity and fraud and abuse allegations.

AHIMA’s position does not call for an outright elimination of copy-and-paste functionality within EHR systems but instead encourages strong technical and administrative controls including organizational policies and procedures, requirements for participation in user training and education and ongoing monitoring efforts.  The statement recognizes that copy-and-paste functionality can increase efficiency of documentation in a time-constrained environment but notes the time-saving benefits must be balanced with the potential for inaccuracies, fraudulent entries and inconsistent documentation.  Redundant information may make it more difficult for providers to identify current information.  Likewise, the use of copy-and-paste can make it difficult to clearly identify the author of the documentation or when the documentation was first created.  Progress notes may also become unnecessarily lengthy when copy-and-paste functions are used.

The position statement outlines recommendations for a variety of public and private sector stakeholders including EHR system developers and healthcare provider organizations.  Recommendations to industry stakeholders include the development of “best practice” standards and collaboration with HIM professionals to provide practical solutions to information integrity, management and governance challenges.  With respect to EHR system developers, AHIMA calls for system design and usability standards and implementation specifications to promote accurate and compliant documentation as well as ways in which provider organizations can configure systems to limit, record and audit copy-and-paste functionality.  The statement also looks to CMS to confirm the permitted use of copy-and-paste functions under the Medicare Conditions of Participation and provide educational examples of appropriate uses for copy-and-paste functionality within EHRs.

AHIMA’s position statement raises important concerns regarding the use of copy-and-paste functions in EHRs.  Healthcare providers utilizing EHR systems with copy-and-paste capabilities should look for ways to effectively implement technical and administrative controls in order to maximize efficiencies while ensuring the accuracy and integrity of their medical record documentation.

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