It’s so easy to do—just use the “copy and paste” feature in an electronic health record (EHR), and all the prior information about a patient appears in the document. No need to retype patient history. The feature can be fast, simple, and seems safe to use.
But is it?
According to experts, not always.
“Why is copy and paste a bad idea? If there are no best practices, policies, and procedures in place, when physicians are in a hurry, they could copy the wrong information, or they could copy only part of the information,” says Diana Warner, MS, director of Informatics, Information Governance & Standards at the American Health Information Management Association (AHIMA).
Overuse or incorrect use of the copy and paste feature in EHRs can be dangerous and can have legal ramifications, including insurance fraud or loss of money from billing errors due to convoluted information for coding, Warner says. Also called “cloning” and “carrying forward,” the copy and paste feature has benefits—including saving time during vital documentation, which is especially useful with the heightened importance of the EHR Incentive Program (also known as “Meaningful Use”)—but the risks can be high.
In “Appropriate Use of the Copy and Paste Functionality in Electronic Records,” AHIMA notes that using copy and paste incorrectly can result in “redundant, erroneous, and/or incomprehensible health record documentation.” For example, if a patient has a family history of breast cancer but no diagnosis of the disease and a practitioner accidentally copies only “breast cancer,” leaving off “family history of,” the patient’s medical history would then be inaccurate, Warner says.
And the practice is more common than one might think. An August 2017 study in JAMA® found that, of 23,630 notes written by 460 clinicians, more than 80% of text was copied or imported from a previous document. Only 18% of text was manually entered.
With so many practitioners using the copy and paste feature, more awareness about potential issues, as well as collaborative solutions from all involved, is needed, Warner says. Several questions should be asked when developing policies and procedures:
- When should you copy and paste information?
- What areas can you copy and paste?
- What review and editing is required of the provider so only relevant and up-to-date information is included in the document?
In addition, the ECRI Institute held a workshop in 2016 that identified 4 safe practice recommendations for using copy/paste features:
- Make copy and paste material easily identifiable
- Cite the origin of copy and paste material clearly
- Train and educate staff about the appropriate and safe use of copy and paste
- Monitor, measure, and assess copy and paste use consistently
Not all information needs to be copied from previous notes and other documents, and knowing what to edit can help prevent “note bloat,” when documents such as progress reports become overwhelming from copying too much content, Warner says. Practitioners should retain key patient history as well as updated notes so patients receive the most accurate care. In essence, practitioners should be storytellers.
“What is the patient story for that day or that visit?” Warner says. “Sometimes it gets lost. And that’s what makes documenting difficult.”