AHIMA calls for strict health record cut-and-paste parameters

The common but sometimes controversial practice of copying and pasting information from a patient's earlier electronic health record into a new one is permissible only “in the presence of strong technical and administrative controls,” according to a just-released position statement by the American Health Information Management Association.

The AHIMA's seven-page advisory, “Appropriate Use of the Copy and Paste Functionality in Electronic Health Records,” said there should be a joint responsibility between users and developers of EHRs to ensure that record systems can be configured to appropriately handle copy-and-paste functions, “including recording copy and paste user actions, audit capabilities and reporting.”

Providers are seeking a balance between the time savings that copying and pasting portions of a record afford, such as updating routine demographic information and unchanged clinical conditions, and inappropriate uses that could jeopardize patient care or lead to billing fraud.

HHS Secretary Kathleen Sebelius and U.S. Attorney General Eric Holder sparked the controversy in November 2012, when they sent sternly worded letters to five top healthcare organizations warning that federal officials were dialing up investigations into the possible misuse of electronic record-keeping systems to overbill Medicare.

Providers have since pushed back, pointing fingers at the developers of health information technology systems.

Nevertheless, AHIMA also calls on providers to be required “to develop policies and procedures to assure compliance with governmental, regulatory and industry standards.”

“Reliable and accurate EHRs are essential to empowering patients and physicians with real-time information to improve quality of care,” said AHIMA CEO Lynne Thomas Gordon in a release accompanying the advisory. “All healthcare organizations have a responsibility to ensure the integrity of EHRs.”

Follow Joseph Conn on Twitter: @MHJConn