On March 17, 2014, the American Health Information Management Association (AHIMA) issued a position statement outlining its view on the appropriate use of the copy/paste functionality in electronic health records (EHRs). AHIMA’s position is that copy/paste functionality in EHRs should be permitted only in the presence of strong technical and administrative controls, including policies and procedures, user training and education, and ongoing monitoring. For organizations using copy/paste functionality, the benefits (efficiency and time savings) should be weighed against the risks (potentially inaccurate or compromised records). The risks open an organization up to legal issues such as fraud and abuse and medical errors.
AHIMA made the following recommendations for health care provider organizations:
- Develop policies and procedures addressing the proper use of copy/paste to ensure compliance with governmental, regulatory and industry standards
- Address the use of features such as copy/paste in information included in governance processes
- Provide comprehensive training and education on the proper use of copy/paste to all EHR system users
- Monitor compliance and enforce policies and procedures regarding the use of copy/paste — institute corrective action as necessary
AHIMA’s position statement also included a number of recommendations for industry stakeholders, EHR system developers and the public sector.