There's a huge difference between a patient with a "family history of cancer" and a "history of cancer," but if you copy and paste notes in your practice's EHR system, that one-word difference can cause lots of trouble for physicians, practice employees, and of course, the patient if altered.
Diana Warner, director of health information management (HIM) practice excellence for the American Health Information Management Association (AHIMA), gave the above example of just one of the drawbacks of copying and pasting patient information from one record to another at this year's Medical Group Management Association Annual Conference in San Diego. Warner's session, entitled "Copy That: Are You in Compliance?" was held on Monday, Oct. 7.
Warner said that the use of EHRs has "made it easier for the auto insertion of" data as providers and other practice staff rush to complete mountains of paperwork associated with each patient each day. But one of the key risks of copying and pasting patient information is information integrity, from inaccurate data to redundant information to propagation of inaccuracies.
"Once you have inaccurate data … it is in your system, in other providers' systems [you share that data with], payers, and others," she said.
In addition, more patients are accessing their records due to the meaningful use requirements to provide records to patients at their request. Imagine if your patients find incorrect information in their record, sloppy spelling, or other mistakes. That time-saving effort of copying and pasting could foster distrust of the information and possibly of your practice, Warner said.
"You need your records to have integrity," she said. "…If patients see erroneous data, they will question [your practice's] reputation and question the physician."
There are five areas, however, where copying and pasting information can be appropriate, said Warner. They are: demographics; medications; allergies; problems; and labs, treatments, and therapies, she said. In most cases, this information does not change from visit to visit, but always "use the information for that patient at that time," she advised.
In addition to facing patient scrutiny over poor health records, don't forget that the government and other payers are cracking down on fraud and abuse. If you are misrepresenting a patient's care — intentionally or unintentionally — you may have to answer for the mistakes.
"Everyone is responsible for correct data," Warner said.
To ensure that your patient data is accurate, she advised auditing for compliance, taking risk management mitigation steps, developing strong procedures at your practice, and ensuring procedures are followed by everyone at the practice.
"In your education, just don't say 'Don't do it'… talk about why," said Warner. "Talk about the compliance issues, about patient safety issues. Then look at what you can do to make [patient record keeping] easier … talk to the vendors to see if you can make work flow [changes]."
Warner identified the following as ideal components of an audit plan: determining how and when audits will be conducted; who will perform the audits; frequency of audits; and a corrective action plan based on the findings.
She also advised talking to vendors about how your EHR system works as well as how and if an "audit trail" can be easily located.
And, of course, resources such as voice recognition software, medical scribes, and dictation/transcription services can reduce the likelihood that staff or physicians will copy and paste in the EHR.
Still, Warner reminded her MGMA13 audience that copying and pasting patient information has a place in healthcare, if used correctly.
"Copy and pasting can be used appropriately, if you have the correct policies and procedures in place," she said. "If you are pulling information, look at it."