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)

Although physicians have always been able to hand copy patient information from preexisting paper records, the electronic health record facilitates this process in a greater magnitude and has been noted to do so without the same sense of personal ownership as it did in paper records (Article 1-page 3/8).

History

Veterans health Administration (VA) 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 at VA in the 1990s started noticing copied text from prior notes onto new notes, a function enabled by 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

A study done at VA hospital in 2003 used plagiarism-detection software to quantify this problem. It was noted that 9% 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. (Hammond 2003)

In another study, 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)

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 Nothing gets deleted- only additons (Hirschtick RE. A piece of my mind. Copy-and-paste. JAMA. 2006;295:2335-2336.)

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)

This also was noted to lead to “lengthy, hard-to-read records stuffed with data already available on line.” (1)

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.

A series of 11 suggestions were made on a ways to decrease the risks associated with copy and paste.

Re-engineer templates to avoid unnecessary duplication artifact. Minimize inserting patient data available elsewhere into the narrative record. Develop medical history and examination data objects that can be reviewed, amended and re-used. Enhance the problem list function as a better alternative to copying text lists. Enhance automated methods to more efficiently monitor for dangerous and misleading copying. Caution clinical departments against excessive use of copying to boost productivity. Teach practitioners and students that careless copying creates untrustworthy records. Empower teachers to monitor the writings of trainees with automated methods. Adopt policy stating that unethical copying is unacceptable. Promote ethical electronic documentation early in training. Require source attribution when copied text is re-used in patient records.

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)

References

Submitted by (Raghavendra Mishra, MD)