The electronic health record EHR is a more longitudinal collection of the electronic health information of individual patients or populations. The EMR, in contrast, is the patient record created by providers for specific encounters in hospitals and ambulatory environments, and which can serve as a data source for an EHR.
Copying clinical documentation can be a time-saver for busy clinicians. It also can pose a risk to document integrity. For organizations that allow use of the copy functionality in their EHR systems, part of keeping compliant with organizational, state, and federal requirements is auditing the practice for proper use.
Ensuring Documentation Integrity Copying forward clinical documentation is the process of copying existing text in the record and pasting it in a new destination. Clinicians may use it to save time when updating notes on an existing patient.
It is also known as copy and paste, cloning, and carry forward, among Meaningful use of ehrs terms. Carrying existing information forward may be appropriate when the copied information is: Based on external and independently verifiable sources, such as basic demographic information that is stable over time Clearly and easily distinguished from original information, such as automatic summaries that populate data fields that are clearly identified as nonoriginal and cannot be mistaken for original information Not actually rendered as part of the record until after a re-authentication process and also auditable for identifying actual origination Thoughtfully and appropriately managing copy functionality requires that organizations have sound documentation integrity policies.
This is especially important given that EHR implementations change operational processes and documentation and workflow practices within the organization.
The use of copy functionality without the ability to review, test, audit, and approve presents significant medical and legal risks see sidebar. With appropriate checks and balances in place, however, prudent use of the functionality can be systematically evaluated so that documentation integrity is ensured.
Even organizations that have barred the use of copy and paste through policy will still require auditing if the copy function is available in its EHR system and cannot be turned off. HIM professionals can take a leadership role in addressing copy forward processes by listening, conversing, and collaborating with other stakeholders within the organization.
Determining System Audit Capability Ensuring that copied documentation follows all appropriate organizational, state, and federal requirements requires system tracking audit trailsobserving organizational use, and testing system capabilities.
How an organization approaches this task depends in part on the record system it uses. Some early electronic documentation systems have allowed functionality that would not be considered acceptable today—for example, cloning encounters or copying content without attribution to the original source.
More recent EHRs address this loophole. In all cases, however, organizations must confirm how the functionality works in their particular systems.
If organizational policy bars a given use of copy and paste but the system supports that action, the organization must decide how this behavior will be monitored and measured. Some systems will be capable of tracking and detecting the action and can report retrospectively on who used the functionality, as well as how and when they employed it.
Organizations should not assume that even certified products provide the ability to audit copy functionalities. The certification criteria from the Certification Commission for Healthcare Information Technology do not require that copy functionalities of any type be auditable events.
Developing an Audit Plan Organizations can develop an audit plan by first determining how providers plan to use the copy functionality. If the intention is to allow the copy of documents from one system to another e.
The organization should test each of the proposed uses. Testing may require thorough investigation to systematically identify what can be audited and what cannot. An interdisciplinary approach including HIM professionals, IT staff, and perhaps system vendors is recommended. See sidebar for sample testing activities.
HIM professionals are a key participant in the development of copy audits, in part because of their knowledge of essential state, federal, organization-specific, and Joint Commission documentation requirements. To that end, they can ensure that all of these standards are identified, reviewed, and met in conjunction with the proper implementation of the copy functionality.
Failure to consider these key documentation requirements can result in inaccurate or erroneous information within the health record, even potentially a deficiency from an accreditation body.
Timely reporting is also a key part of the process to ensure that the audit results are reported to the appropriate organizational committee, and it should be a part of the ongoing review process.
Violations of the copy policy should be identified, validated, and rectified through factual documentation. Such action should take place in an appropriate timeframe. Copy Risks Using the copy functionality in an EHR system poses risk to documentation integrity, including: Following are three copy functionalities recommended for testing.
Ideally the system has a test environment or other means to make sure that testing does not have problematic impact on the actual patient information system. While they are not comprehensive tests, the following three points provide a first set of screening questions to apply and target areas for further investigations:The American Reinvestment & Recovery Act (ARRA) was enacted on February 17, ARRA includes many measures to modernize our nation's infrastructure, one of which is the "Health Information Technology for Economic and Clinical Health (HITECH) Act".
-use of certified EHR in a meaningful manner -use of certified EHR technology for electronic exchange of health information to improve quality of health care -use of certified EHR technology to submit clinical quality measures & other such measures.
The U.S. Department of Veterans Affairs (VA)’s new $billion-dollar Cerner electronic health record (EHR) system will use open application programming interface (APIs) and Fast Healthcare Interoperability Resources (FHIR) standards to enable interoperability with the private sector, according to a Cerner executive, which potentially positions the VA as a leading force to drive.
Meaningful Use is defined by the use of certified EHR technology in a meaningful manner (for example electronic prescribing); ensuring that the certified EHR technology is connected in a manner that provides for the electronic exchange of health information to improve the quality of care; and that in using certified EHR technology the provider must submit to the Secretary of Health & Human Services (HHS) .
The first steps in achieving meaningful use are to have a certified electronic health record (EHR) and to be able to demonstrate that it is being used to meet the requirements. Stage 1 contains 25 objectives/measures for Eligible Providers (EPs) and 24 objectives/measures for eligible hospitals.
Background. In , CMS established the Medicare and Medicaid EHR Incentive Programs to encourage Eligible Professionals EPs, eligible hospitals, and CAHs to adopt, implement, upgrade (AIU), and demonstrate meaningful use of certified EHR technology (CEHRT).