Question

As a HIM professional within Anywhere Hospital’s HIM department, you have been asked to review physician documentation within the hospital’s new EHR system, implemented six months ago. Your goal of the review is to catch any documentation issues early and work with the appropriate hospital leadership to fix those issues. As you review the documentation within your facility’s EHR, you notice that physicians are utilizing the copy and paste functionality available within the EHR system, allowing physicians to select health record documentation from one source or from one section of the EHR and replicate it in another source or another section of the record. You notice in one particular instance that the health record identifies a patient as a 65-year-old male (as identified during the registration process), but in the progress notes is described as a 25-year-old female who has given birth. Clearly, the physician utilized the copy and paste functionality inappropriately and copied health record information from a health record of a patient who was a 25-year-old female and pasted that information accidentally into a health record of a 65-year-old male. You find this concerning because this could have patient safety concerns, as well as billing and claims issues and the use of this functionality could open the facility up to potential claims of fraud and abuse by the payer. You take this concern to your leadership and a multidisciplined group of hospital employees including HIM professionals, nurses, physicians, and billing and revenue cycle employees to discuss and fix the problem. There are mixed opinions about the copy and paste functionality. Some individuals feel this feature is a time-saver and a productivity booster while others believe it only opens the hospital up to additional CMS scrutiny.What should be considered when deciding whether or not to use the copy and paste functionality? Why? What controls might be put in place related to the copy and paste functionality? How effective could these be? What alternatives to the copy and paste functionality are available? What are the pros and cons associated with each option?

Answer 1

What should be considered when deciding whether or not to use the copy and paste functionality? Why?

Copy and Paste function may be the time saver for clinicians but it increases the errors and mistakes in clinical documentation. Federal regulatory standards and safety concern about the privacy and confidentiality of patient information should be considered. The HIM professional should consider the risks of copy and paste function and its limitations. Concern about the awareness and effective handling of copy and paste function by the HIM professionals and needs of any training and education.

What controls might be put in place related to the copy and paste functionality?

Avoid the use of multiple screening at a time. Open one window at a time. The policies should be regulated. Develop an audit plan to check and control the issues related to copy and paste function and to make an alternative. Sample copy paste testing should be done. The limitation and prohibition should be set.

How effective could these be?

Opening of one window at a time will avoid false propagation of information. Regulating Organizational policies will improve safety concerns and proper use of information. Audit plan helps to identify the problems and to make necessary changes. The involvement of HIM professionals, IT staff, IT vendor will resolve the issues associated with Copy and paste functionality. The sample of copy and paste functionality priorly help to identify the system functions, needs of correction, and other mitigation. It helps to use the copy and paste functionality effectively.

What alternatives to the copy and paste functionality are available?

EHR design should be changed according to the safe use of copy and paste function. Additional facilities of reporting, auto correction, auditing should be included in the EHR design. Auto refill or drop-down options will be the best alternative for copy and paste which will minimize the errors and improve the efficiency in clinical documentation. Voice recognition software will also helpful in minimizing of error instead of dictation and typing. The multidisciplinary team of HIM professional should develop policies, rules, limitations in using of these features and to discuss the risks.

What are the pros and cons associated with each option?

Changes in the EHR system:

Pros:

• Provide accurate information and correction.
• Time-saving.
• Auto auditing.

Cons:

• More software to implement.
• Increase of cost.
• Misuse of Physician notes.

Auto refill:

Pros:

• Easy to use.
• Minimum time.
• Cost-benefit.

Cons:

• Lack of privacy.
• Time-consuming.

Voice recognition:

Pros:

• Increases accuracy
• Increases confidentiality
• Easy to access and speed
• Avoid spelling errors.

Cons:

• Limited vocabulary.
• Need more training.