AHiMA’s Position Statement Concerning Use of EMR “Copy and Paste” Calls for Industry Development of “Best Practices” and of Formal Guidance from ONC

by Leonardo M. Tamburello

The American Health Information Management Association (AHiMA) issued guidance this week intended to address the use of “copy and paste” functionality in electronic health record systems (EHRs).  As previously discussed on this blog, this comes in the wake of two recent reports issued by the Office of the Inspector General (OIG) which called on CMS to address this fraud and abuse concern which is unique to EMRs by developing formal guidance on the use of EHR “copy and paste” functionality.  In support of its recommendations, AHiMA cites a recent article published in MDAdvisor written by McElroy Deutsch attorney, Leonardo Tamburello.

AHiMA calls for broad collaboration among industry stakeholders, EHR system developers and the public to insure the appropriate use of copy/paste functionality in EHRs and reduce the risks associated by improper design and use.  It proposes that both public and private sector organizations work together to implement a number of recommendations, including that:

  • Industry stakeholders collaborate on the development and promulgation of “best practices” for monitoring compliance with governmental, regulatory and industry standards related to clinical documentation;
  • EHR systems be designed to allow organizations deploying them to configure the use of copy/paste functionality, including the recording of copy/paste user actions, audit capabilities and reporting;
  • the Office of National Coordinator for Healthcare Information Technology (ONC)  continue to address EHR usability issues which may present potential risks for quality of care, patient safety and fraud, and that ONC develop formal guidance for the appropriate use of copy/paste within the EHR certification criteria.

Many of AHiMA’s recommendations echo those made by the OIG’s recent reports, such as those related to the need for formal guidance on the use of EHR copy/paste and strengthened reliability of EMR audit logs.

The full text of AHiMA’s position statement is available here.