Providers must take steps to prevent adverse patient safety events caused by use of an electronic health record's copy-and-paste function (CPF), according to an alert from The Joint Commission.
The alert acknowledges that while CPF can improve efficiencies, foster prompt communication and increase time with the patient, there are risks associated with its use, including:
- Copying and pasting inaccurate or outdated information
- Redundant information in the EHR, which makes it difficult to identify the current information
- Inability to identify the author or intent of the documentation
- Inability to identify when the documentation was first created
- Propagation of false information
- Internally inconsistent progress notes
- Unnecessarily lengthy progress notes
The Joint Commission has received reports to its Sentinel Event database regarding these documentation errors, data integrity and patient harms attributable to CPF, and notes that as adoption of EHRs increase, the potential for patient harm due to CPF will also increase.
"All organizations that use EHRs should be aware of the risks of the CPF and collaborate with their healthcare providers to ensure this tool does not lead to unintended consequences that may result in patient harm," the alert states.
The Joint Commission recommends that providers take several steps to reduce the safety risks of CPF, such as:
- Work collaboratively to balance the benefits of the CPF with the potential risks, and develop training and education related to the CPF
- Have a process where the accuracy of the clinical record is monitored
- Begin a focused and ongoing professional performance evaluation with specific triggers and measures related to the accuracy of the clinical record
- Maintain robust quality review process(es) in which all cases of potential misuse or error due to CPF are evaluated consistently and comprehensively to identify opportunities for improvement in patient safety
The Joint Commission also recommends that providers follow the recommendations of the American Health Information Management Association, such as enforcing policies and procedures regarding use of CPF, with corrective action if necessary.
Others have expressed concern about the improper use of CPF rendering the EHR inaccurate and enabling providers to bill and code for services they're not entitled to. Last year the Office of Inspector General found that only one-fourth of hospitals studied had policies on the use of CPF to reduce the risk of billing fraud and recommended that the Centers for Medicare & Medicaid Services develop guidance on use of the feature.
To learn more:
- here's the alert