EHR Copy and Paste and Patient Safety
Although the ability to copy and paste text is a central benefit of computing in general, and electronic health records (EHRs) in particular, the widespread adoption of EHRs has led to concerns about how copy-and-paste functionality is being employed in health care. It has been 5 years since Hirschtick wrote a WebM&M commentary on a remarkable case that illustrates some of the problems associated with copy and paste.(1) In that case, the patient with an alleged history of "PE" (interpreted by the clinicians as pulmonary embolism) received an unnecessary CT scan to rule out a suspected "recurrence" of pulmonary embolus. As it happens, years earlier, the abbreviation "PE" had been used in the electronic note to indicate that the patient had had a physical examination, not a pulmonary embolism! In a vivid example of copy and paste, once the diagnosis of pulmonary embolism was mistakenly given to the patient, it lived on in the EHR. Unfortunately, Hirschtick's call to action at the time, along with those of others over the years (2,3), has not resulted in the kind of improvements in provider documentation that might prevent harm from copying and pasting.
The use of copy and paste in medical documentation raises many concerns. As in the case discussed by Hirschtick, the use of copy and paste may contribute to the introduction of inaccurate information within patients' records and cloud the judgment of subsequent providers. Copy and paste also makes it easy to create long, rambling notes that do not clearly convey the current status of a patient and can, in fact, distract a reader from important concerns. Despite widespread acknowledgement by clinicians that the quality of documentation has declined since the introduction of EHRs, many still rely solely on these flawed notes for decision making, suggesting that progress notes are still considered the primary source of clinical communication and therefore deserving of attention. Although restricting the copy-and-paste function is technically feasible within the EHR itself, clinicians typically oppose such drastic measures.(4) The fact that we continue to use a tool that we acknowledge as unsafe without taking real action to improve its use is a blot on our profession.
Perhaps we are complacent about copy and paste because we remain unconvinced that there is a correlation between its use and patient safety. While a systematic review of published studies identified 13 publications and two abstracts addressing prevalence of copy and paste, just two studies were identified that demonstrated a relationship between copy and paste and clinical outcomes.(5) The first was focused on identifying contributors to diagnostic errors in primary care clinics. Singh and colleagues identified 190 diagnostic errors.(6) Expert review determined that more than 35% of the errors could be attributed to copying and pasting mistakes.(6) The second study, by Turchin and colleagues, found that copied and pasted lifestyle counseling in patients with diabetes was less effective in controlling glucose than "net new" counseling statements.(7) Other studies allude to an impact of copy and paste on patient safety but do not demonstrate causality.(4,8,9)
Even though Hirschtick proposed technology, education and mentoring, or acceptance as potential solutions 5 years ago (1), it is clear that much work remains to be done. We have seen some progress in developing consensus around the appropriate use of copy and paste. Several professional organizations have published consensus statements and toolkits, which can be used for the basis of education and mentoring around this issue.(10-12) In the technology realm, a few vendors have developed tools for easily identifying copied and pasted material and the provenance of the copied content. For example, Epic's EHR can now identify the source of every character within a note, whether it is newly typed, imported from another source, or copied and pasted. Wang and colleagues recently published a report documenting their use of this technology.(13) Despite this technical capacity, I am aware of very few organizations that are actively using these tools to educate and mentor clinicians in a systematic way to improve documentation quality. Moreover, little has been written about documentation improvement initiatives that address copy and paste.(14-16)
So, despite clear evidence of potential for harm, for now we may be left with "acceptance." A cross-sectional survey at four institutions found that though attendings and residents agreed on the purpose of a progress note, the perceived effect of implementing an EHR on the quality of a note was different across the two groups.(17) In particular, housestaff viewed the copy-and-paste function to be "neutral" or "somewhat positive," while attendings felt its effect was "neutral" or "somewhat negative." As a new generation moves into supervisory roles, this study suggests that acceptance of copy and paste may be the norm. If this is the case, we most certainly need to provide oversight in the use of copy and paste and provide critical feedback to our trainees and to our peers when we see it being used inappropriately. Documentation review may need to be incorporated into peer review processes in order to heighten the importance it plays in communication and patient safety.
It seems clear that we need more research examining the potential link between copy and paste and patient safety outcomes. But even as the research base expands, we already have published guidelines and toolkits for the safe use of copying and pasting. We now need organizations to start using these toolkits and auditing features to help elucidate how best to educate, implement change, and incorporate supportive technologies.
Finally, we need to examine a variety of strategies—both technological and otherwise—to see their impact on improving the inaccuracies introduced with copy and paste. For example, we should explore natural language processing and its potential role in helping providers review their documentation for accuracy. We should research the impact of voice recognition software on provider efficiency and how this may influence providers' sense that they "need" to use copy and paste. The OpenNotes initiative—which allows patients to read their clinicians' notes—represents another real opportunity for heightening provider awareness of the need for documentation accuracy, as patients will now also be able to hold us accountable for quality documentation. Lastly, the potential impact of payment reform, with its focus on quality and outcomes, cannot be underestimated, as it may allow the note to be used more for clinical communication rather than for billing or coding, thereby freeing the provider from the perceived need to include extraneous information.
Ultimately, physicians need to reestablish ownership of the accuracy of clinical documentation. We must stop blaming the EHR for our carelessness and start educating ourselves about how to use documentation efficiency tools, including copy and paste, more responsibly.
Shannon M. Dean, MD
Chief Medical Information Officer–UW Health
Associate Professor of Pediatrics
University of Wisconsin School of Medicine and Public Health
Department of Pediatrics
Division of Hospital Medicine
5. Tsou AY, Lehmann CU, Michel J, Solomon R, Possanza L, Gandhi T. Safe practices for copy and paste in the EHR. Systematic review, recommendations, and novel model for health IT collaboration. Appl Clin Inform. 2017;8:12-34. [go to PubMed]
7. Turchin A, Goldberg SI, Breydo E, Shubina M, Einbinder JS. Copy/paste documentation of lifestyle counseling and glycemic control in patients with diabetes: true to form? Arch Intern Med. 2011;171:1393-1394. [go to PubMed]
8. Hammond KW, Helbing ST, Benson CC, Brathwaite-Sketoe BM. Are electronic medical records trustworthy? Observations on copying, pasting and duplication. AMIA Annu Symp Proc. 2003;269-273. [go to PubMed]
11. Shoolin J, Ozeran L, Hamman C, Bria W II. Association of Medical Directors of Information Systems consensus on inpatient electronic health record documentation. Appl Clin Inform. 2013;4:293-303. [go to PubMed]
14. Fanucchi L, Yan D, Conigliaro RL. Duly noted: lessons from a two-site intervention to assess and improve the quality of clinical documentation in the electronic health record. Appl Clin Inform. 2016;7:653-659. [go to PubMed]
15. Bierman JA, Hufmeyer KK, Liss DT, Weaver AC, Heiman HL. Promoting responsible electronic documentation: validity evidence for a checklist to assess progress notes in the electronic health record. Teach Learn Med. 2017;29:420-432. [go to PubMed]