The case of Anywhere Hospital’s HIM department focuses on the use of functions in EHR, which makes the physicians’ work easier and increases their productivity. The case identified that overuse of the copy and paste function could result in mistakes in patients’ health records. The issue presents a common problem in the healthcare system, and there are different opinions on the topic, with some prioritizing the efficiency of the function.
Considering the requirements or prohibitions of using the function in EHR, the American Health Information Management Association (AHIMA) points to the possibility of errors in documentation with misuse of the function. Thus, while the function is not prohibited, its use is discouraged by AHIMA’s regulatory requirements because it can result in “redundant, erroneous, and/or incomprehensible health record documentation” (as cited in Boyle, 2018). The current EHR system was implemented in Anywhere Hospital six months ago. While the system is designed to assist physicians and make their work easier, the current functionality detracts from the quality of the department’s documentation. Furthermore, the system’s copy and paste function negatively influence physicians’ attention to documentation, giving the process a routine character. Thus, by preferring to complete the documentation through copying and pasting information, the system does not provide additional assistance to specialists and imposes risks to the integrity of health records documentation.
Furthermore, there are different alternatives for the copy and paste function, which also increases the documentation’s efficiency but utilizes better organizational processes. For example, some companies offer software solutions that allow the implementation of voice commands for patient records entry in EHR. The solution addresses the problem of the routine nature of filling the data and increases physicians’ attention, improving documentation accuracy. Lastly, considering the standards that Anywhere Hospital’s facility can implement in organizational documentation, the leadership can provide technical assistance to physicians in the documentation process. Alternatively, the leadership can require physicians to indicate the source of the copied data in patients’ records.
Reference
Boyle, E. L. (2018). Copying and pasting in EHRs. DukeHealth.