Copying and pasting information is common within EHRs, but the practice sometimes can lead to confusion and endanger patient care reports Kevin B O’Reilly of American Medical News. Coined “Sloppy & Paste”, the practice of carelessly copying and pasting previous information is widespread across medicine and can lead to mix-ups that sometimes cause harm to patients. The problem is even more epidemic with the rise of EHRs. According to one physician, “It’s especially problematic when you have multiple teams taking care of the patient and we’re communicating through the chart, which happens very often nowadays because physicians don’t see each other as often as we used to.”
A study in February’s Critical Care Medicine found that copying and pasting is the rule in EHRs rather than the exception. The study examined 2068 progress notes of 135 patients generated by 62 residents and 11 attending physicians. The results concluded that 82% of all residents, and 74% of all attending notes contained greater than or equal to 20% copied information A similar study in the January-February 2010 issue of the Journal of the American Medical Informatics Association, found a copy-and-paste rate of 78% in sign-out notes generated by internal medicine residents. The rate of copied text in progress notes was 54%, the study said.
“Such findings are representative”, says Robert Hirschtick, MD, “It’s an epidemic, and it’s among people who should know better." Dr. Hirschtick is the associate professor of medicine at Northwestern University Feinberg School of Medicine in Chicago, and has written widely about sloppy and paste. “The common characteristic is that it’s a tremendous, time-saving shortcut for people too busy to do it the right way. The right way is to make sure everything in that note you’re about to sign reflects what’s going on today.”
While entirely disabling the copy-and-paste function in EHRs would eliminate the problem, it also would make documentation much more time-consuming. There seems to be consensus among physicians, as well as patient safety and health IT experts that such a move would be overkill. Some suggest that EHR systems should automatically flag copied-and-pasted text by highlighting or underlining it, though some experts worry that this would only make long progress notes even more difficult to quickly scan and comprehend.
Meanwhile, incidents of actual patient harm (or near misses) are growing. One such event involves the case of a 77-year-old woman hospitalized for diarrhea and dehydration after chemotherapy. An intern noted that the patient would receive heparin to prevent venous thromboembolism. The note was copied and pasted for four days in a row, and signed by a resident and an attending physician who appeared to believe the heparin had been ordered. Ultimately, the patient was discharged without ever receiving the preventive medicine and was later re-hospitalized with a pulmonary embolism.
The Dept. of Health and Human Services’ Office of Inspector General says it too is concerned about misuse of copy-and-paste in electronic systems. In October 2012, the OIG announced that it plans to review multiple EHR notes for the same patient by the same physician to see whether doctors are copying and pasting identical notes, from visit to visit. The practice is sometimes called cloning and could be implicated in fraudulent coding and billing practices.
As possible solutions, the Dept. of Medicine at Weill Cornell Medical College created EHR documentation guidelines to emphasize that copy and paste “should be used with extreme care.” But others propose a more radical fix. “The way we document in medicine has grown up over decades for medical reasons, for billing, for medical-legal justification,” said Dr. Halamka, chief information officer at Beth Israel Deaconess Medical Center in Boston. “You wind up with 17 pages of replicated and duplicated and challenging-to-read documentation. I propose we blow up the way we do documentation altogether and replace it with a Wikipedia-like structure. With that concept, you wouldn’t ever really need to copy and paste.”
Such an approach would allow physicians to edit progress note collaboratively, just as the popular open-source encyclopedia is updated. Dr. Halamka hopes to pilot-test the idea within the next year.
Sources:American Medical News – (2013. February 4). EHRs: “Sloppy and paste” endures despite patient safety riskKEVIN B. O'REILLY, amednews staff. http://www.ama-assn.org/amednews/2013/02/04/prl20204.htm
Critical Care Medicine - Prevalence of Copied Information by Attendings and Residents in Critical Care Progress Notes* (2013. Feb). Thornton, J. Daryl MD, MPH1,2; Schold, Jesse D. PhD, MStat, Med3; Venkateshaiah, Lokesh MD2; Lander, Bradley BA4 - http://journals.lww.com/ccmjournal/Abstract/2013/02000/Prevalence_of_Copied_Information_by_Attendings_and.2.aspx
“Electronic Health Record Documentation Guidelines V 1.2, 2012-2013,” Dept. of Medicine, Weill Cornell Medical College, New York-Presbyterian Hospital
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