As we have written about in previous posts, the Office of Inspector General (OIG) for the United States Department of Health and Human Services (HHS) has been critical of the copy/paste function that is available in electronic health record (EHR) technology developed by software vendors.  (See “Electronic Health Records in OIG’s Sights for 2013“, October 20, 2012; “OIG recommends fraud safeguards in hospital EHR technology“, December 11, 2013; “OIG Report on CMS’ EHR Audit Practices Concludes The Practices Are Not Very Sophisticated“, February 11, 2014)  As our February 11, 2014 post concludes, while turning off the copy/paste functionalities are not the immediate solution to preventing a misuse of the function, health care providers should implement standards for its use.  The American Health Information Management Association (AHIMA) recently issued guidance, “Appropriate Use of the Copy and Paste Functionality in Electronic Health Records,” dated March 17, 2014, discussing the availability and appropriate use of the copy and paste function.

AHIMA supports maintaining the copy/paste functionality in ONC’s EHR certification standards and allowing for its use in CMS Conditions of Participation.  AHIMA encourages CMS to augment provider education and training materials on the appropriate use of copy/paste in order to reduce the risk that it may pose to quality of care, patient safety and fraudulent documentation.  Importantly, AHIMA recommends that health care providers implement policies and procedures to guide users of EHRs on the proper use of copy/paste functionalities.  To read the AHIMA guidance, click here.