June 5, 2017

The EHR Crisis: Pervasive and Dangerous Copying and Pasting

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A study just out by researchers at the University of California’s San Francisco Medical Center reviewed more than 23,000 progress notes over an eight-month period and found that less than 15 percent constituted new and unique content. Residents were the worst offenders, with 88.2 percent of their text being copied and pasted.

It is disheartening to see that copying and pasting is still such a pervasive problem, despite cloning having been a specific target of the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG); previous studies had cited the rate of copy-and-paste in electronic health record (EHR) notes being between 54 and 82 percent.

The dangers of excessive copying and pasting include propagation of inaccurate, outdated, or incomplete information; internally inconsistent text; note bloat (“chartomegaly”), wherein salient information is masked by redundant or irrelevant documentation; and worst of all, squandering an opportunity to look at a patient with fresh eyes. Providers are skipping the “think” before they “ink” in a push to be productive, and this is jeopardizing patient care.

This was not an issue with paper medical records. You would never copy the entire history of present illness into every interval history, because that would be the opposite of time-saving. Healthcare providers might document the impression of a radiology study to advance the understanding of why specific conclusions were drawn and diagnoses were made, but it would be ludicrous to “import” the type and amount of contrast used into one’s daily progress note.

A three-day-old complete blood count (CBC) that preceded a transfusion performed yesterday would not be handwritten into today’s progress note. I once had to admonish a consultant who copied and pasted the referring physician’s entire history and physical (H&P) into his own documentation, including, “consult (me).” This is called “fraud.”

Turning off the function in your EHR is not the solution. As I discovered when I observed residents performing their daily functions, any practitioner with the most rudimentary computer savvy can CTRL-C (copy) and CTRL-V (paste) into a word processing document, edit the text, and return it to the EHR, without leaving an audit trail.

I think the solution is multifactorial. Education is a good start, but EHR technology must assist. There should be a mechanism for identifying non-original text (e.g., different font), and the provenance must be readily available (i.e., source, author, date/time). The creation of novel, up-to-date documentation should be at least as easy as copying and pasting (e.g., voice recognition, dictation, scribing).

It is imperative that institutional auditing and monitoring practices are established and implemented on a routine basis. Providers must be given specific feedback on the utilization of copying and pasting; examples of cases that imperil a patient are also powerful teaching tools, and should be redacted and disseminated.

The American Health Information Management Association (AHIMA) put out a position paper in 2014 regarding the appropriate use of copying and pasting (http://bok.ahima.org/PdfView?oid=300306), and ECRI Institute has an excellent toolkit freely available, titled “Health IT Safe Practices: Toolkit for the Safe Use of Copy and Paste:” (https://www.ecri.org/Resources/HIT/CP_Toolkit/Toolkit_CopyPaste_final.pdf). It is critical that any initiative to reduce or eliminate copying and pasting has the support of the entire hospital, institution, or system, as a culture shift is necessary for success.

Convenience is compelling. To counteract the addiction to copying and pasting, we must continually remind providers that the primary purpose of clinical documentation is to ensure excellent clinical care for our patients.

I think the key to ward off bad habits is to practice my motto: Put “mentation” back into documentation!
Erica E. Remer, MD, FACEP, CCDS

Erica Remer, MD, FACEP, CCDS has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, clinical documentation improvement (CDI), and ICD-10 expertise. As a physician advisor for University Hospitals Health System in Cleveland, Ohio for four years, she has trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016. Dr. Remer is a member of the ICD10monitor editorial board and the co-host of Talk-Ten-Tuesdays. She is also on the board of directors of the American College of Physician Advisors.

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