With physicians getting more and more comfortable with the usage of an EMR and EHR Software, the use of shortcut keys and copy/paste methods has increased. While this has proved useful and has greatly made the use more efficient, this has also posed a lot of threats. When the copying and pasting functionality in an Electronic Medical Records (EMR) Software is used inappropriately by physicians, instead of saving time and improving efficiency, it can cause major patient safety issues.
Normally, EHR, EMR and PM software are not the cause of safety-related issues, but they can play an important role in this matter. Practices must keep this in mind and keep their eyes open to what’s going on with the software system. An over-dependence on the EHR Automation and Shortcuts turns out to be the main reason behind such issues. The attendees need to realize that these shortcuts come in many forms, requiring user validation. Some of these shortcuts are:
- Direct copy and paste either through mouse or through the keyboard (Ctrl + C to copy and Ctrl + V to paste) from one source to another.
- Cloning (Duplicating) of Notes
- Auto-completion i.e. Automatic population of text in text fields
- Auto-fill i.e. Drawing data from an external record and automatically inserting it with a specific command
When doctors copy and paste data often in a Practice Management (PM) software system, they may risk the reliability of the information. The original data from the source might be real-time and accurate, but when it is copied, its integrity becomes questionable.
Copied Documentation sometimes also causes over-abundance of data in the Electronic Health Records (EHR) Software which may also cause physicians to leave important information unnoticed. And all of this can eventually lead to an error in the diagnosis of the patient. The patient information becomes so long and complex that the true picture becomes clouded and the physicians are unable to find out what is really going on with the patient.
The tips given below will help you ensure compliance when using copy and paste functionality in your EMR system.
Communicate with your EMR Software provider
Stay in touch with your EMR Software provider to make sure that copy/paste instructions are clear and the results are easily identifiable. This step will help you verify data for accuracy, and will facilitate review for making changes or editing.
Accurate Copying and Pasting
Make sure that the information you copied is easily traceable to the original source. This is another step to make sure that all of the data was copied accurately with minimum errors. This may also help achieve billing compliance and defend the record.
Training of Staff and Employees
Work on the training of staff and employees regarding proper and secure use of the copy/paste functionality. Staff training might cost in the short run but will always prove useful in the longer run.
Federal and State Regulations
Carefully and critically observe, assess, and rate the copy/paste practices. If done regularly, this step can help ensure the reliability and integrity of the records in the EHR Software, and also make the records comply with the federal and state regulations.