Pitfalls of Copy-Paste in Electronic Health Records

Propagating outdated, inaccurate information

Female doctor using laptop in hospital, rear view
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Copy-paste is one of the most useful functions available to users of any electronic documentation system. Clinicians use electronic health records (EHRs) to document the details of a healthcare encounter. Such details include the symptoms that the patient is reporting, physical exam, test results, diagnosis, assessment and treatment plans. When the patient’s problem is recurrent or chronic, the clinician needs to document updates on the same problem on a repeated basis.

In order to increase efficiency, the clinician may use copy-paste to bring forward portions of the documentation from one record to the next.

While copy-paste is a convenient tool for busy clinicians, it can lead to inaccurate, misleading and potentially dangerous errors in the EHR. Concerns have also been raised about nurses using copy-paste and copy-forward in flow sheets, resulting in potentially inaccurate or outdated information being carried over. This article will focus on the clinical pitfalls of inappropriate copy-paste.

Outdated information affecting patient care

The main problem is that information that was once accurate becomes inaccurate if it is not updated to reflect the patient’s current status. With copy-paste, it is all too easy to propagate information and neglect to update it.

For example, consider the following description of a patient hospitalized for pneumonia who develops swelling of the left leg on the third day of the hospital course.

The attending physician orders an ultrasound to determine if the leg swelling is due to a deep venous thrombosis (blood clot). The brief summary at the end of the physician’s note includes the description of the patient’s pneumonia treatment as well as the following statement:

“Left leg swelling. Venous Doppler ultrasound ordered.”

Later that day, the physician learns that the ultrasound is negative.

The following day, in order to save time, she uses the copy-paste function and inserts the same summary statement from the previous day into the note. But she neglects to update the note with the ultrasound results.

Since she didn’t update the information, the record is now outdated and therefore inaccurate. It states that the ultrasound status is “ordered,” but the ultrasound has actually been performed and the results are known.

Fewer and fewer EHR notes entered manually

Outdated, inaccurate medical records can affect patient safety, especially when other clinicians (like specialists and consultants) rely on the note to keep up to date with a patient’s progress. The potential for error is multiplied if the inaccurate information is propagated throughout the patient’s record in the EHR and other connected health information systems.

This problem can occur in inpatient and outpatient records. In 2013, assistant professor Daryl Thornton of Case Western Reserve University in Cleveland led a study that found 82 percent of notes in an intensive care unit created by resident physicians (in training) and 74 percent of notes created by attending physicians (fully trained) contained at least 20 percent copied information in the section containing the assessment and plan.

In August 2017, a study was also published in the Journal of the American Medical Association (JAMA) that showed the situation pertaining to copy-and-paste data remains worrying to date. Researchers from the University of California, San Francisco analyzed inpatient progress notes written by 460 clinicians over a period of 8 months. They concluded that less than one fifth of the notes was manually entered. Often, doctors copied or imported their entries. Residents used these techniques more frequently than medical students, the former entering just over 10 percent of their notes manually. 

Another disadvantage of copy-paste is that it discourages clinicians from exercising critical thinking skills in analyzing, summarizing and communicating the patient’s status in progress notes.

With copy-paste, progress notes can easily become bloated with extraneous, outdated information while obscuring the most important details about a patient’s status.

Best practice recommendations to curb risks

The American Health Information Management Association recommends that “The use of copy/paste functionality in EHRs should be permitted only in the presence of strong technical and administrative controls which include organizational policies and procedures, requirements for participation in user training and education, and ongoing monitoring.

While copy-paste may increase efficiency in certain circumstances, the benefits need to be weighed against the potential for creating outdated, inaccurate and unnecessarily lengthy documentation in the EHR.

To increase patient safety and the quality of notes, different strategies have been proposed. For example, in line with current hospital and institutional policies, copied and imported content should be clearly identifiable and the original author, time and date of entry noted.  Also, the final author needs to be aware that he or she is responsible for all content of the signed document. This should encourage clinicians to meticulously update and review their notes. Many large health-care institutions now also prohibit or restrict students from copying notes.

Generally, a thoughtful and measured approach has been favored, which needs to include staff education and careful monitoring of notes.

Sources:

Patterson E, Sillars D, Moffatt-Bruce S, et al. Safe Practice Recommendations for the Use of Copy-Forward with Nursing Flow Sheets in Hospital Settings. Jt Com J Qual Patient Saf. 2017;43:375-385

The American Health Information Management Association. Appropriate Use of the Copy and Paste Functionality in Electronic Health Records.  2014

Thornton JD, Schold JD, Venkateshaiah L, Lander B. Prevalence of copied information by attendings and residents in critical care progress notes. Crit Care Med. 2013 ;41(2):382-8. doi: 10.1097/CCM.0b013e3182711a1c

Wang M, Khanna R, Najafi N. Characterizing the Source of Text in Electronic Health Record Progress Notes. JAMA Internal Medicine. 2017;177(8):1212-1213

Weis J, Levy P. Topics in Practice Management: Copy, Paste, and Cloned Notes in Electronic Health Records. Chest. 2014;145:632-638.

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