Copy and paste

Copy and paste function (CPF) in electronic health records (EHR) allows physicians to copy a patient note from a previous time, insert it under a new date and time and alter it, rather than writing a new note each day. (Article 2- page 63)

History

Veterans health administration was the first healthcare system to transition to a clinical information system with electronic order entry and patient documentation functions called Computerized Patient Record System (CPRS). Health information managers and clinicians in the 1990s noticed copied text from prior notes onto new notes with the aid of the word processing tool on computers. The tool along with the ability to use templates supported the difficult transition from paper to electronic documentation. However, with increasing frequency of use in the copy and paste functionality in clinical documentation began to raise concerns about errors, patient safety and quality of narrative.

Prevalence and perceptions among providers

In a cross sectional survey, it was noted that 90% of providers used the copy and paste EHR function. 70% reported using it almost always or most of the time. 71% noted that this function led to inconsistencies and inaccuracies in documentation. Only 24% felt CPF led to mistakes in patient care and 19% felt copy and paste function had negative impact on patient documentation in EHR. 80% providers wanted to continue using this function. (Article 2 O’Donnell,2008)

This also was noted to lead to “lengthy, hard-to-read records stuffed with data already available on line.” (1) This author completed a VA study of Computerized Patient Records System (CPRS) charts that showed that nine percent of progress notes they inspected contained copied or duplicated text, and that high-risk author copying occurred once in every 720 notes, and one in ten electronic records contained an instance of high-risk copying. A series of 11 suggestions were made on a ways to decrease the risks associated with copy and paste. Another author has noted that “…the use of NLP may allow a much more precise method to carry text forward from previous notes, which may alleviate some problems caused by uncontrolled cutting and pasting of text.” (2)

Benefits

Studies report physicians spend more time in indirect patient care, specifically fulfilling the responsibility of data entry than at the patient bedside. (ER 4000 click study). Copy and paste functionality is a legitimate timesaving tool when used appropriately. (article 1, page 2/8)

Limitations and concerns

Copying a note in EHR without editing or updating it creates opportunities for error and patient harm. Such practice has been referred to as “sloppy and paste” in a commentary published by the Agency for Healthcare Research and Quality (AHRQ) patient safety network. (Article 1 page 2/8). Medication reconciliation errors fall under the high risk category in EHR copy and paste errors. (Mazer 2011, acad emerge med)

“Note bloat” issue

CPF has been shown to cause significant redundancy in the clinical narrative from duplication of prior information making it harder to find new and meaningful information. The quality of sign outs followed by progress notes is affected the most. (Article 3- O’Wrenn- quantifying clinical narrative)

Possible solutions

Technological solutions such as automatic EHR highlighting of copy-and-pasted text in the form of color coding or italicizing has been proposed. This difference in appearance of a copied-and-pasted text would prompt readers to heighten their skepticism regarding the text’s accuracy.

Increased focus on regular auditing and feedback on provider noted has been proposed to improve clinical documentation practices.

References

Submitted by (Raghavendra Mishra, MD)