What is the potential impact of the copy paste functionality on the integrity of the data and information contained in an EHR?

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1. What is the potential impact of the copy/paste functionality on the integrity of the data and information contained in an EHR? The copy/paste function opens the possibility for fraud, medical error and risk for malpractice claims. Fraud could occur when a copy/paste function is used and than an insurance company is billed for the procedure/services 2 or 3 times. When in reality the procedure/service was only completed once. Medical error can occur with the copy/paste function, when a nurse reads a chart made by a doctor who copy/pasted instructions or initiates a procedure that was already completed but the doctor didn't realize that they copy/pasted it again. Than the nurse completes the procedure again, which can…show more content…

Don't let staff get lazy and complacent with using the copy/paste function. 1. What impact can a hybrid record have on patient care?

The hybrid record could have negative and positive effects on patient care. One negative effect would be that it would take longer to access and put together if a whole file is requested. Another negative would be just where exactly is all of these paper records being kept. A positive effect of the hybrid record is that if the computer system is compromised in some way there would be a paper record.

2. How might the hybrid record change health information management? The hybrid record would change health information management because you would have to have employees to care for all these records, as well as employees for the computer files thus creating more staff and costing more. There would of course have to be training on how to properly handle the hybrid record having thus an effect on the health information management team. Who would have to implement training, schedule personnel off to take the training find yet others to cover for that training. Again costing more money and time.

3. How might a hospital overcome some of the issues created by the hybrid record? To overcome some issues created by the hybrid record you would have to have good education/training in implementation of new data, new software and soft- ware

Healthcare documentation integrity refers to the accuracy of the electronic health record (EHR). Outsourcing medical transcription goes a long way when it comes to maintaining error-free medical records. Dictation and transcription are used alongside structured templates. Studies have revealed that when physicians enter patient encounter data into EHRs, they tend to use the copy-paste function to save time.

It is estimated that 66% to 90% of clinicians routinely use copy and paste. Research published in Applied Clinical Informatics referenced a study of diagnostic errors which reported that copy and paste led to 2.6% of errors in which a missed diagnosis required patients to seek additional unplanned care. Another study from the University of California San Francisco Medical Center found that up to 80 percent of the content in a typical progress note is copied or imported by clinicians and this undermines the validity of the notes.

Structured vocabulary enables efficient decision support and analysis of data, but carelessly copying structured data from note to note without proper evaluation can affect document integrity and compromise patient safety. It’s crucial that physicians know how to use the EHR copy-paste function safely and effectively.

Copy-Paste – Potential Risks to the Integrity of the Medical Record

With the copy-paste function, clinicians can easily reproduce information such as text, images, and prior test results or medication lists, and other data in documents – based on the assumption that these elements might remain constant from visit to visit. Clinicians also tend to copy paste information like medical histories and discharge summaries from previous patient notes to save time. The copy-paste functionality was designed to improve the ease and efficiency of clinical documentation, foster communication, and importantly, allow physicians to spend more time with patients. However, despite these benefits, the copy/paste function can pose risks to the integrity of the medical record. Potential risks include:

Copying and pasting information that is inaccurate or outdated
Superfluous information in the EHR, which makes identifying current information a challenge
Not being able to identify the author or intent of the documentation
Inability to identify when the documentation was created
Propagation of incorrect information – errors may be repeated in the record for months and even years
Inconsistent progress notes
Note bloat or progress notes that are too lengthy, making it difficult for future members of the care team to analyze the details of a patient’s medical care

Inappropriate use of copy/paste could also lead to reimbursement fraud. If too much of information is pulled from a previous note with properly reviewing it, physicians may end up unintentionally documenting services that were completed during an earlier visit, raising questions of misrepresentation or even fraud. A survey by the Medical Professional Liability Association identified copy and paste as the main factor in EHR-related malpractice allegations, and a claims data analysis enabled by CRICO Strategies also reported that copy and paste is a key user error contributing to malpractice lawsuits (www.medpro.com).

So, what’s the way out? Is it to disable the copy-paste function? No, say experts.

“There’s no question that copy-and-paste can be misused or overused, but it’s also a helpful function for reducing burden when it’s appropriately used, says Dr. Christopher Longhurst, chief information officer at UC San Diego Health. “There’s a place for it, and turning it off completely is not helpful.” (www.modernhealthcare.com).

Measures for Safe Use of Copying and Pasting

Steps that physicians can take to promote safe use of copy-paste, including recommendations from the American Health Information Management Association:

Establishing policies on where copy-paste can be used and where it cannot to assure compliance with governmental, regulatory and industry standards.
Address copy-and-paste utilization in the organization’s information governance processes and monitor physician adherence to the policies.
Encouraging physicians to adequately edit the copy-pasted information to ensure it is still up-to-date and relevant for the patient’s current care.
Train and educate all EHR system users on proper use of copy-and-paste.
Establish corrective action as needed.

Structured entries are required in EHRs for demographics, vital signs, smoking status, problem list, medication list, medication allergies, lab tests/values, and at least one family history entry. According to Medical Economics, one report, up to 91% to 93% of data entered in structured forms can be captured via dictation, transcription, and free-text entry.

The Bottom Line: Since appropriate use of the copy-paste function is crucial for patient safety and documentation integrity, physicians should use this EHR feature with caution. Medical transcription services can help with EHR documentation, allowing providers to focus on the patient during the office visit. With EHR voice-recognition software, physicians can directly dictate into the system and have the automated notes reviewed for accuracy by an experienced medical transcription service provider.

Medical Transcription Services, Outsourcing Medical Transcription