Copy and Paste in ED: "Dangerous Practice"
Don't rely on inaccurate information
An elderly man presented to an emergency department (ED) with new-onset chest pain. In reviewing the patient's electronic medical record (EMR), the emergency physician (EP) noted a history of "PE," but the patient denied ever having a pulmonary embolus. Further investigation revealed that many years earlier, the abbreviation had been used to stand for "physical examination," but someone had mistakenly copied and pasted "PE" into the patient's past medical history. The error was carried forward for years.1
Cutting and pasting of an ED patient's history without verifying the data is risky, as there is no guarantee that the information being copied into the new record is accurate and current, warns Edward Boudreau, DO, FACEP, FAAEM, president and CEO of Epic, a Roseville, CA-based professional liability insurer.
"What is meant as a time saver and efficiency booster can indeed be a dangerous practice," says Boudreau. However, some ED EMRs allow for past medical history from previous visits to be imported into a current document.
"Most physicians would not consider reviewing the paper record of a prior visit and copying it verbatim into the record for a new visit without verifying it with the patient, especially if they do not know that particular patient," says Boudreau.
If EMRs automatically populate data into new records, "the clinician can ill afford to accept any imported document without careful review," warns Sam Bierstock, MD, founder of Champions In Healthcare, a consulting company in Delray Beach, FL, specializing in advising hospitals, physicians, and technology companies on implementing EMRs and health care information technology.
For instance, an EP might import the history and physical from a patient's initial visit for an injury when the patient returns three weeks later with a wound infection. If the patient had been in the ED with an unrelated event in the interim, information from the wrong visit could be imported.
"The problem arises, in general, from the reluctance of many hurried clinicians to deal with structured data entry and templates," says Bierstock.
An ED nurse might use "copy and paste" to document that a patient has no reported history of cardiac risk factors, without realizing that the history stored in the EMR was recorded before the patient was seen at another facility with an ST-elevation myocardial infarction the previous year.
"A physician who relies on this information and fails to verify it with the patient risks making a potentially critical error regarding the patient's plan of care and the need for admission versus discharge," says Boudreau. The EP would surely be named in the claim if a bad outcome occurred, he adds, even though the error stemmed from nursing documentation.
Samantha L. Prokop, JD, an associate at Brennan, Manna & Diamond in Akron, OH, says that one of the most common issues related to EMRs she sees in emergency medicine litigation involves copying and pasting outdated or incorrect information. "It is important that if the copy and paste function is used, that the health care provider independently verify the information and indicate this in the record," she advises.
Here are some legal problems that can result from use of copy and paste functions for ED documentation:
The EMR autofills data fields.
For example, if an ED nurse is documenting fluid intake and output every hour, the EMR might allow the nurse to enter the volume in and out the first time, and automatically populate that same information every hour.
If the nurse gets busy, forgets to change the values, or looks at the record and thinks he or she has already completed the documentation because it's in the record, the values never get changed.
"Imagine you have a lawsuit a year later where the intake and output information is crucial," says Prokop. "The plaintiff now puts the records in front of your nurse and asks why she never reported to the physician that the patient had no urinary output for 12 hours."
The nurse might claim that he or she would have called the physician, and questions why all the entries are the same, says Prokop, but the defense later learns that the nurse was unaware that the data were being automatically filled in by the EMR. "Further, we discover that the nurse's 'live' computer screen looks different than the final medical record that the medical record department prints out and provides in litigation," says Prokop.
The ED nurse has no idea what her documentation looks like in final format, and has no idea that when she electronically signs off on a record as being accurate, she may not be viewing all applicable information, explains Prokop.
The copy and paste function is used to document assessments that never occurred.
Vital signs might be documented consistently in the patient's chart, but interestingly enough, are all identical. "When the IT department performs an audit of the documentation, it is apparent the nurse created one entry at the end of her shift and copied and pasted all other entries within minutes of the first entry," Prokop says. She recommends EDs use these risk-reducing strategies:
Create policies and procedures indicating limitations on the copy and paste function, and set forth who is responsible for verifying the accuracy of the information if the copy and paste function is used;
Implement an auditing process for copied and pasted entries, and keep track of the error rates;
Provide education to practitioners on the patient safety risks and financial risks of using a copy and paste function improperly;
Educate practitioners on how their entries in the "live" version of the computer screen will appear in the official legal copy of the medical record, to avoid inconsistencies and ensure that all information is accurately reflected;
Ensure that the EMR has an audit function to track copied and pasted entries and ensure that it is being used to monitor such entries;
Implement a process to notify practitioners when copy and paste functions were improperly used, or information was not accurately recorded;.
Implement a mechanism where copied and pasted entries will look different than manual entries, such as italicized text or different colors;
Ensure that copied and pasted data are attributed to the original author, and indicate that the practitioner reviewed and verified the data in the current assessment; and
Consider disabling the copy and paste functions for certain fields.
John Lee, MD, an EP and informatics director at Edward Hospital in Naperville, IL, says these parts of the EP's documentation lend themselves to inserting predetermined content:
data entered by other providers, such as nurses, physicians, or other ancillary staff, either during the current visit or carried forward from previous visits;
data generated by diagnostic or therapeutic departments, including lab and radiology results; and
content in template format, either from the information system or the documenter. "For instance, a doctor may always have a certain pattern when performing a physical exam," says Lee.
In the past, EPs would have to actively search for this type of information to incorporate it into a note, making errors unlikely, says Lee. "The ease, speed, and volume of current electronic systems make it much more likely a key piece of data may be missed or erroneous information entered," he says.
Lee says that resulting conflicting documentation will hurt an EP's credibility in the event a lawsuit is filed. For instance, an EP might document a normal musculoskeletal exam in a patient who has had an amputation, or order a test to rule out a disorder that the patient has already been determined to have.
"However, I also believe that these issues will become less of an issue as more of the data become discrete, and that data circle back to the clinician in the form of decision support," says Lee.
Switching from the subjective/objective/assessment/plan format to the assessment/plan/subjective/objective format should make copying and pasting in EMRs less relevant, adds Lee, as "it will highlight our cognitive processes better and deemphasize the copy forward data."
Reference
1. "Case Report: Sloppy and Paste." [Commentary by R. Hirschtick]. July 2012 AHRQ Web M&M: Morbidity and Mortality Rounds on the Web. Agency for Healthcare Research and Quality, Rockville, MD. Available at http://webmm.hrq.gov/case.aspx?caseID=274.
Sources
For more information, contact:
Sam Bierstock, MD, Champions in Healthcare. Phone: (561) 243-3673. E-mail: [email protected]. Web: www.championsinhealthcare.com.
Edward Boudreau, DO, FACEP, FAAEM, President/CEO, Epic, Roseville, CA. Phone: (916) 772-2080.
John Lee, MD, Emergency Department, Edward Hospital, Naperville, IL. Phone: (630) 527-5144. E-mail: [email protected].
Samantha L. Prokop, JD, Brennan, Manna & Diamond, Akron, OH. Phone: (330) 253-3766. E-mail: [email protected].
An elderly man presented to an emergency department (ED) with new-onset chest pain. In reviewing the patient's electronic medical record (EMR), the emergency physician (EP) noted a history of "PE," but the patient denied ever having a pulmonary embolus.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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