Copy-and-paste is so easy and time-saving that it can be tempting to overuse it in the medical record, and some electronic medical records encourage clinicians to use blocks of text over and over. However, liberal use of copy-and-paste can diminish the quality and reliability of an electronic medical record.
Some medical records even routinely repeat blocks of text from previous versions of the note, without the user manually doing so.
Copied information in a medical record can mislead clinicians in several ways, says Diana Warner, MS, RHIA, CHPS, FAHIMA, director of health information practice excellence with the American Health Information Management Association (AHIMA) in Chicago. For instance, information that was accurate when first entered may no longer be accurate, but is copied forward into the current version of the note.
Copying too much information also promotes “note bloat,” in which the record becomes so large that it is difficult to find what you’re looking for, Warner says. “You also can have redundant information that makes it difficult to see what is new in the record. If you see the same thing over and over, it can make it hard to see what is new and notice any noteworthy additions, to know what’s going on with the patient right now,” she says. “There also is the danger of copying and carrying forward incorrect information, or maybe you didn’t copy the full text that you needed. Maybe the patient has a family history of breast cancer, but you only copied history of breast cancer, and now that is going to totally change how you look at and treat that patient.”
The legal veracity of the note can be compromised, and overcopying can result in both undercoding and overcoding, Warner says.
The risks posed by overuse of copy-and-paste were illustrated in a recent study led by Michael D. Wang, MD, a physician in the Department of Medicine at the University of California, San Francisco (UCSF). (An abstract of the report is available online at: http://bit.ly/2wqepeJ.) While previous studies on copied text could not distinguish manually modified text from automatically updated, imported values in electronic note templates, Wang’s study used a new tool that distinguishes manual, imported, and copied text in hospital progress notes.
Wang and his colleagues studied records from an inpatient electronic record at the UCSF Medical Center. They analyzed 23,630 inpatient progress notes written by 460 clinicians, including direct care hospitalists, residents, and medical students on a general medicine service over an eight-month period.
They found that 18% of the text was manually entered, 46% copied, and 36% imported. Residents manually entered less (11.8% of the text) and copied more (51.4%) than did medical students (16.2% of the text manually entered and 49% copied) or direct care hospitalists (14.1% of the text manually entered and 47.9% copied).
With less than one-fifth of note content manually entered, Wang says the results cast doubt on the validity of many electronic records.
“A better system is like the tool we used that lets you see what was imported from the previous version or a template, and what was manually entered that day. Those manual entries are usually what you’re looking for,” he says. “That separation of the pure clinical note from the other functions of the electronic record, like billing or clinical history, are key to ensuring the validity of the text that clinicians are depending on.”
Wang and his colleagues suggest in the paper that more electronic records could be designed so that copied and imported information is readily visible to clinicians as they are writing a note, but not stored as a permanent part of the note.
In the meantime, Wang suggests educating clinicians about the risks and, particularly, the dangers of depending too much on a copied clinical history.
“They will rely on that clinical history, but is that medical record really the best place for that clinical history to live? Maybe it should live somewhere else so the clinical history is not compromised and isn’t overwhelming the part of the record the provider wants to access,” Wang says. “But that’s something we have to work on with our vendors.”
Wang’s research also revealed a belief among some clinicians that more text leads to higher billing, which he says should be addressed with education on why that is not so.
When medical records are compromised by overuse of copying, so is patient safety, Warner says.
“Simply making the record too long and full of too much text is a danger. When you have providers wading through so much text, especially blocks of repeated text, they may not have the time to go through all of that and pick out what one bit of information is key for the patient’s care at that moment,” she says. “Particularly in an emergency situation, the provider may look at all that text and decide there’s no time for that. They will act on what they normally do in this situation without that information available.”
Hospitals should address the risk through policies and workflow analysis, Warner says. Identify when clinicians are using copy-and-paste and why, then educate them about the potential dangers. Implement policies that specify when it is allowed, she suggests. (AHIMA offers guidelines on copy-and-paste use at: http://bit.ly/2eqwwsC.)
“There may be alternatives that could be offered, such as using scribes to capture information during a patient encounter, and systems that use voice recognition,” she says. “There are times when it is OK to copy information and bring it forward, such as a past surgical history or similar information that has not changed since the last visit.”