Anyone who uses a computer or other device routinely takes advantage of the copy-and-paste feature to save time and effort, but how appropriate is that when you’re working in an electronic medical record (EMR)? It can be done safely, but only if you are aware of the potential risks and use the feature wisely, experts say.
The use of copy-and-paste in EMRs was the focus of a recent work group at ECRI Institute in Plymouth Meeting, PA. Experts from healthcare organizations studied how copy-and-paste is used and the potential effects on quality, patient safety, and legal risks. The group determined that there are significant risks, says Lorraine Possanza, DPM, JD, MBE, senior patient safety, risk, and quality analyst for ECRI.
“One of the biggest problems is when you are copying incorrect, outdated, or inappropriate information into a chart,” Possanza says. “Even if you’re going back into the patient’s record and pulling information that was valid at that time, you have to ask if the information is still accurate and relevant. It’s one thing to copy the past surgical history — a fairly static list — but quite another to copy an assessment from when the patient presented with a similar condition two years ago.”
Copying an assessment or similar material creates a cognitive bias in all clinicians using that record afterward, presenting the information as current when in fact it may be from years ago, Possanza explains.
Both Risks and Benefits
The ECRI task force identified several risks and benefits of copy-and-paste. The risks included producing notes with internal inconsistencies; creating more queries or work to determine if information is correct; erosion of confidence in the documentation either for provider or the health record in general due to outdated, inaccurate, or misleading information; interfering with effective communication among providers because important findings and problems are intertwined with normal patient information; producing overwhelmingly long charts and notes; and the perceived need to “fill” the note for billing and regulatory requirements. (The ECRI report is available online at http://bit.ly/28YYlnU.) The ECRI work group developed four recommendations for the safe use of copy-and-paste. (See the recommendations in the story later in this issue.)
But as serious as those problems are, copy-and-paste should not be eliminated because it offers valuable benefits as well. ECRI points to these positive results from the prudent use of copy-and-paste, saving time by allowing for information that does not readily change to be easily transferred, efficiently capturing complex information, improving tracking of multiple problems for complex patients by providing an easy way to continually document care, improving continuity of care by allowing a simple way to transfer important information to other providers, reducing transcription errors, and reducing the risk of neglecting important issues.
Possanza points out that copy-and-paste is different from cut-and-paste. Copying text can be efficient and safe when done properly, but cutting text in a medical record is never acceptable because it amounts to altering the record, she explains. That is not only bad medicine but also exposes the hospital and clinician to legal liability, she says.
“That is an important distinction the work group made,” Possanza says. “There is a big difference and the work group was clear in saying that cut-and-paste has no place in working with a medical record.”
Most Lack Policy
Another significant risk from copy-and-paste is that the medical record can be cluttered with repetitive or unneeded information, Possanza says. Lab results, for instance, may be lengthy and detailed when just a few values are important for the patient’s care. If the clinician copies and pastes the entire lab report instead of entering just the pertinent data, the next person using the record will have to wade through the entire lab results. That increases the chances that vital information will be overlooked, she says.
“It makes the note exceptionally long, and you cause the reader to lose the train of thought, and maybe forget what you opened the record to look for in the first place,” Possanza says. “It makes decision-making more difficult and clogs the communication between providers.”
Possanza notes that a recent survey by the HHS OIG found that only 23% of hospitals had a policy on cut-and-paste, so the issue has still mostly overlooked.
“Individuals who have grown up in an electronic environment expect to use copy-and-paste and they don’t understand why it can be such a problem,” she says. “Copy-and-paste also leads to a bloated medical record because you very easily take a big chunk of text and duplicate it elsewhere, whereas the doctor probably wouldn’t have taken the time to write that much if it had to be entered manually. The longer and more complex the chart is, the more likely that something will be overlooked.”
Educating people about the risks and safe ways to copy-and-paste is the first step in addressing the issue, Possanza says.
“There are inherent risks and we have seen incidents where copy-and-paste led to patient harm,” she says. “In one case, the record incorrectly indicated that the person had received anticoagulant prophylaxis and that got carried forward for several days. The person ended up getting deep vein thrombosis, and that probably would not have happened if the error wasn’t copied and pasted into the record over and over.”
SOURCE
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Lorraine Possanza, DPM, JD, MBE, Senior Patient Safety, Risk and Quality Analyst, ECRI, Plymouth Meeting, PA. Email: [email protected].
Special Recommendations
The work group studying the risks and benefits of copy-and-paste for the ECRI Institute in Plymouth Meeting, PA, developed these four recommendations:
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Recommendation A: Provide a mechanism to make copy-and-paste material easily identifiable. The group noted that copy-and-paste can help ensure completeness of encounter documentation and generally produces fewer transcription errors, but copied material should readily identifiable so that it can be confirmed and validated.
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Recommendation B: Ensure that the provenance of copy-and-paste material is readily available. Knowing where the copied information came from is important in ensuring the accuracy and appropriateness of information that will be used to make clinical decisions. The provenance can help alert clinicians to information that is inaccurate, out of date, or from an inappropriate source, such as information mistakenly copied and pasted from the wrong patient record.
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Recommendation C: Ensure adequate staff training and education regarding the appropriate and safe use of copy-and-paste. Hospitals should outline proper procedures for copying and pasting information to standardize the process. This also will facilitate regulatory compliance and ensure that the record will be useful in the litigation setting.
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Recommendation D: Ensure that copy-and-paste practices are regularly monitored, measured, and assessed. An audit policy will allow hospitals to monitor how copy-and-paste is used so that potential problems can be identified.
