Patient and Hybrid Record

1. What is the potential impact of the copy/paste functionality on the integrity of the data and information contained in an EHR? The copy/paste function opens the possibility for fraud, medical error and risk for malpractice claims. Fraud could occur when a copy/paste function is used and than an insurance company is billed for the procedure/services 2 or 3 times. When in reality the procedure/service was only completed once. Medical error can occur with the copy/paste function, when a nurse reads a chart made by a doctor who copy/pasted instructions or initiates a procedure that was already completed but the doctor didn't realize that they copy/pasted it again. Than the nurse completes the procedure again, which can have fatal results. Thus opening the door for malpractice and even criminal suits. Thus the integrity of the whole file would have been compromised by on click of a button.

2. How does copy/paste functionality affect reimbursement? The copy/paste function can affect reimbursement because your insurance could get billed several times for the same procedure that was only completed once. Than your insurance could potentially deny the whole procedure leaving you with the bill and the headache of getting it sorted out. The other side of the coin is that with copy/paste function being used could make it to where someone else's insurance gets billed if the last copied document is from another’s file than they clicked onto your file and though they highlighted something new but didn't causing a whole new set of problems.

3. What measures can a hospital take to improve data integrity in their EHR while still achieving their goal of streamlining the documentation process? There needs to be educational training on the functionality of the copy/paste function and when and where it should and should not be used. EHR professionals need to come up with some new software applications that would cut down on the amount