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Copy-Paste The Good, The Bad, The Ugly

Copy-Paste The Good, The Bad, The Ugly. Jennie Bryan, MBA, RHIA, CCS Compliance Audit Manager Crowe Healthcare Risk Consulting. November 9, 2018. Course Objectives. At the end of this session, you should be able to: Define copy/paste and other similar EHR functionality

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Copy-Paste The Good, The Bad, The Ugly

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  1. Copy-PasteThe Good, The Bad, The Ugly Jennie Bryan, MBA, RHIA, CCS Compliance Audit Manager Crowe Healthcare Risk Consulting November 9, 2018

  2. Course Objectives At the end of this session, you should be able to: • Define copy/paste and other similar EHR functionality • Identify what is good, bad and ugly about this functionality • Identify methods to assess and mitigate risks

  3. Activity: POLL

  4. EHR Adoption By Hospitals

  5. EHR Adoption by Physicians

  6. Definitions

  7. THE GOOD

  8. The Good - Benefits of Copy/Paste • Saves time for the clinician • Creates efficiency capturing information • Reduces transcription error • Improves the ability to track multiple issues in highly complex patients • Improves completeness of encounter documentation

  9. The BAD

  10. The Bad - Risks of Copy/Paste • Data integrity (outdated, inaccurate) • Note bloat • Repetitious or irrelevant information • Author attribution/integrity • Inability to identify when the information was first created • Inability to accurately support or defend E/M codes for billing

  11. The UGLY

  12. The Ugly - Billing, Fraud and Abuse • Billing Concerns • Fraud and Abuse • Record doesn’t stand up to litigation

  13. The Ugly – Quality of Patient Care https://www.youtube.com/watch?v=M24uGjgX0yA

  14. Activity: POLL

  15. Example 1

  16. Example 2

  17. How to Mitigate Risk1 • Provide a mechanism to make copy and paste material easily identifiable • Ensure that the provenance (chronology of ownership) of copy and paste material is readily available. • Ensure adequate staff training and education regarding the appropriate and safe use of copy and paste. • Ensure that copy and paste practices are regularly monitored, measured, and assessed. 1ECRInstitute. Partnership for Health IT Patient Safety. Health IT Safe Practices: Toolkit for the Safe Use of Copy and Paste

  18. More • Have a policy, set guidelines-develop a consensus around the appropriate use of CPF (more difficult than it sounds) • Provide input to vendors • Copied material must be sourced • Identified process to report inaccuracies or misuse • Disciplinary policy

  19. What is the Author’s Responsibility?

  20. Risk Assessment Questions - Vendor • Can Copy/Paste be easily identified in the record? • Are there ways to monitor it’s use? • Are there other alternatives/functionality that can be used to discourage the use of copy/paste? • Is the original source (date, time, author) of the information visible in the record? • Is the original source information traceable in the audit functionalities?

  21. Risk Assessment Questions - Organizational • Does the organization have an EHR documentation policy and/or Copy/Paste Policy? • Have all stakeholders been educated regarding the policy or education specific to safe uses of copy/paste? • Do we track the use of copy/paste? • Do we incorporate documentation (the use of copy/paste) into peer review activities? • Are we encouraging vendors develop technologies to facilitate safe use and tracking of copy/paste? • Does the organization have a process in place to identify and correct incorrect information? • Is there a corrective disciplinary plan?

  22. Why Should HIM Care? • HIM professionals are responsible for overall documentation integrity • HIM professionals are directly affected by documentation practices • HIM professionals are uniquely qualified to identify gaps within EHRs • HIM professionals are uniquely qualified to provide strategies for auditing documentation

  23. Key Takeaways!

  24. References • AHIMA. “Copy Functionality Toolkit-A Practical Guide: Information Management and Governance for Copy Functions in Electronic Health Record Systems.” • AHIMA.“Auditing Copy and Paste” Journal of AHIMA 80, no.1 (January 2009): 26-29 http://library.ahima.org/doc?oid=87789#.W844uojwa70 • Partnership for Health IT Patient Safety. ECRI Institute. “Health IT Safe Practices: Toolkit for the Safe Use of Copy and Paste”. February 2016. https://www.ecri.org/Resources/HIT/CP_Toolkit/Toolkit_CopyPaste_final.pdf • ECRI Institute, Special Report. “Copy/Paste: Prevalence, Problems, and Best Practices.” October 2015. https://www.ecri.org/Resources/HIT/CP_Toolkit/CopyPaste_Literature_final.pdf • You Tube. TEDx Talks. EHR: The Inflection Point of Medicine: Sunil Bhoyrul. https://www.youtube.com/watch?v=zgwLX2-uBr4 • https://www.youtube.com/watch?v=M24uGjgX0yA • Senator Warren discusses the importance of accurate electronic medical records. (Senate Hearing) https://www.youtube.com/watch?v=eSGeqE_nsYM

  25. Jennie Bryan, MBA, RHIA, CCS Compliance Audit Manager Crowe Healthcare Consulting Jennie.Bryan@crowehrc.com 314-802-2852

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