I attended the American Health Information Management Association (AHIMA) conference during the week of October 16 and learned about the complexities of copy-and-paste in healthcare. It’s a common problem that Extract’s automated data capture can help with.
The copy-and-paste function (CPF) is extremely prevalent in the EHR in efforts to improve efficiencies, foster prompt communication and increase time spent with patients. At the event, I learn that 7.4% of charts contain CPF information. This isn’t good for the following reasons:
- Copying and pasting inaccurate or outdated information
- Redundant information in the EHR which makes it difficult to identify current information
- Inability to identify author or intent of documentation
- Inability to identify when documentation was first created
- Propagation of false information
- Internally inconsistent progress notes
- Unnecessarily lengthy progress notesTo be fair, the CPF isn’t all bad either. CPF is quick, efficient, promotes prompt sharing of information and can increase the time providers spend with patients.
The question is, how do you get the benefit of the CPF without the negative attributes? The following bullets focus on governance which is great but falls short of aggressively solving the “how do we get the work done” problem.
- Develop policies and procedures addressing proper use of the CPF to assure compliance with governmental, regulatory and industry standards.
- Address use of features such as copy-and-paste in the organization’s information governance processes.
- Provide comprehensive training and education on proper use of copy-and-paste to all EHR system users.
- Monitor compliance and enforce policies and procedures regarding use of copy-and-paste, and institute corrective action as needed.
What if Extract’s automated capture software is applied to solve the copy-and-paste problem? This will allow the software to automatically find critical information and present it to a “verifier” who then insures the accuracy of the data. It’s also possible to link the source document to the data as a reference, and it will handle the data very consistently. Extract’s software has also proven to reduce the number of errors being introduced to the patient’s record while streamlining workflows and deduplicating data where redundant information isn’t needed.
For more information on prevening copy-and-paste errors in healthcare, refer to the Joint Commission’s Preventing Copy-and-Paste Errors in EHRs.