By Jennifer Kearney-Strouse
At a lecture on liability and legal considerations on Thursday morning, Adam C. Schaffer, MD, MPH, warned his audience about the perils of copying and pasting.
Despite its dangers, the practice is extremely prevalent, Dr. Schaffer said. He cited a University of California, San Francisco, study from 2017, which found that 18% of text in an electronic health record (EHR) system was manually entered, 46% was copied, and 36% was imported.
"There were a decent amount of physicians who basically copied essentially everything, and then there was a small subset that copied nothing, that completely freehanded their notes," said Dr. Schaffer, who is an assistant professor of medicine at Harvard Medical School and a hospitalist at Brigham and Women's Hospital in Boston. "But the bottom line is that only a very small fraction of the content in the EHR is actually manually entered."
Copying and pasting is also impactful for patient care, explained Dr. Schaffer. A 2013 study found that of 190 diagnostic errors in primary care practices at a VA hospital and a private health system, copying and pasting occurred in 7.4% of the notes and was a contributing factor to the error in 35.7% of this subset.
"Incorrect or outdated information can lead you astray clinically," Dr. Schaffer said. He gave the example of copying and pasting a family history last taken seven years ago that doesn’t include a recent sudden cardiac death in a young relative.
"That could absolutely affect, let's say, some of your diagnostic cardiac testing if the patient has any cardiac symptoms," he said. In addition, he noted that in the event of a malpractice claim, copying and pasting the same note repeatedly can make a physician look clinically inattentive, even if the copy/pasted material is unrelated to the adverse event.
To guard against these and related problems, he offered some recommended practices to apply at the systemic and individual level.
First, on the systems level, enable users to identify which text was copied and pasted by distinguishing written from templated from copied, and make the origin and date of the copied material available by, for example, hovering over the text, he said.
"In some other EHR systems … I have a lot of my colleagues do this, they gray out any text except for the text that was actually typed that day, so it makes it a little bit easier for you to find the proverbial needle in the haystack in terms of what is the new clinical documentation on that patient that's most relevant," Dr. Schaffer said.
On the individual level, in addition to making sure the family history is current, be careful with abbreviations, he said.
"Not that long ago, I had a patient who thought I was completely crazy, because I asked them, 'So when did you have your pulmonary embolism?'" he said. After the patient responded, "What are you talking about? I've never had a blood clot," Dr. Schaffer went into a detailed explanation, thinking maybe the patient just didn't understand the term, but that wasn't the case: "It was a physical exam that somehow migrated down into the problem list as a pulmonary embolism."
Finally, he said, avoid “note bloat" by pasting in only information that is relevant to your patient encounter, and consider separating information that is dynamic from information that is stable (e.g., active issues vs. resolved issues). "Make it so that we just don't have a lot of clinically irrelevant documentation, which is going to be harder for our colleagues, like our consultants and so forth, to find what they need," he said. ■