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

Physicians spend more time in indirect patient care than at the patient bedside. A recent study looked at physician productivity in the emergency room and concluded that approximately 44% of the physician's time in this setting was spent fulfilling the responsibility of entering data in electronic health records. An additional 12% of physician time was spent in reviewing patients' test results and prior data. (ER 4000 click study).

Copy and paste functionality is a legitimate time-saving tool when used appropriately. (article 1, page 2/8). It has the potential to minimize the burden of documentation and hence increase physician productivity and patient-provider satisfaction by allowing physicians to spend more time with patients.

Limitations and concerns

A commentary published by the Agency for Healthcare Research and Quality (AHRQ) patient safety network referred to the practice of copy-paste function in a patient note without editing or updating it as “Sloppy and Paste”. (Article 1 page 2/8). AHRQ is one of the twelve agencies within United States department of Health and Human Services (HHS) and oversees quality and safety in healthcare.

Indiscreet use of the copy paste function in electronic health records may lead to errors and patient harm. A particularly high risk category in copy and paste errors is medication reconciliation (Mazer 2011, acad emerge med) and inaccurate past diagnoses that are carried forward.

Duplication of information caused by CPF also lowers the quality of clinical narrative resulting in “lengthy, hard-to-read records stuffed with data already available on line” (hammond) making it harder to find new and meaningful information. This problem is sometimes referred to as “Note bloat” (Shoolin). A study quantified the phenomenon of redundancy and noted that the quality of sign outs followed by progress notes was affected the most. (Article 3- O’Wrenn- quantifying clinical narrative)

CPF may amount to fraud if the erroneously copied information is used for billing and those services were actually not rendered. (Hammond)

Possible solutions

Both human and technological solutions have been proposed by various authors.

Acknowledging the existence of this problem, promoting discussions and policies at organizational level to facilitate clinician movement towards creating trustworthy records, increased focus on regular auditing and feedback on provider noted have been proposed to improve clinical documentation practices.

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

References

Submitted by (Raghavendra Mishra, MD)