Given “clear evidence of the potential for harm,” a leading physician in Agency for Healthcare Research and Quality’s (AHRQ) Patient Safety Network calls the popular practice of “cut-and-paste” of information within electronic health records (EHR) has been called “a blot on our profession.”
In the January 2018, Shannon Dean, M.D. the Chief Medical Officer (CMO) of the University of Wisconsin School of Medicine and Public Health wrote in the AHRA op-ed that
despite compelling evidence that the cutting and pasting practice increases the likelihood of patient harm, there appears to be growing acceptance of it by new generations of clinical supervisors. Studies shown have documented that this practice leads to inaccurate information, long, rambling notes that do not clearly convey the patient’s current status, the decline of the quality of documentation used for decision-making, diagnostic errors, and less effective guidance to treat chronic conditions, as well as well documented cases of injury and harm. Despite this evidence, a JAMA Internal Medicine study found that more than 82 percent of the 23,630 electronic inpatient progress notes studied were copied or imported. Forty-six percent of notes were copied-and-
Dr. Dean calls on physicians to “reestablish ownership of the accuracy of clinical documentation,… to stop blaming the EHR for our carelessness,” and to increase education on efficient documentation, change management and the effective use of supportive EHR technologies.
Dr. Dean recommends expanded use of –
- EHR meta-data capabilities to track copied or imported notes,
- EHR natural language processing and voice recognition software to increase efficiency and ease review,
- the OpenNotes initiative to enable patients to read their clinicians’ notes and improve accuracy,
- payment reforms tied to quality and outcomes to refocus attention from billing and coding to clinical communication,
- peer review of documentation to using industry based guidance and toolsets, such as:
- Toolkit for the Safe Use of Copy and Paste by the ECRI Institute that convened the Partnership for Health IT Patient Safety Health IT Safe Practices in February 2016. The toolkit focuses making “copy-and-paste” materials identifiable, the origin of the material readily available, staff education on the appropriate use of “copy-and-paste” and are regularly monitor, measure, and assess this practice
- Appropriate Use of the Copy and Paste Functionality in Electronic Health Records by the American Health Information Management Association (AHIMA) (Mar. 15, 2014).