Healthcare documentation integrity refers to the accuracy of the electronic health record (EHR). Outsourcing medical transcription goes a long way when it comes to maintaining error-free medical records. Dictation and transcription are used alongside structured templates. Studies have revealed that when physicians enter patient encounter data into EHRs, they tend to use the copy-paste function to save time.
It is estimated that 66% to 90% of clinicians routinely use copy and paste. Research published in Applied Clinical Informatics referenced a study of diagnostic errors which reported that copy and paste led to 2.6% of errors in which a missed diagnosis required patients to seek additional unplanned care. Another study from the University of California San Francisco Medical Center found that up to 80 percent of the content in a typical progress note is copied or imported by clinicians and this undermines the validity of the notes.
Structured vocabulary enables efficient decision support and analysis of data, but carelessly copying structured data from note to note without proper evaluation can affect document integrity and compromise patient safety. It’s crucial that physicians know how to use the EHR copy-paste function safely and effectively.
Copy-Paste – Potential Risks to the Integrity of the Medical Record
With the copy-paste function, clinicians can easily reproduce information such as text, images, and prior test results or medication lists, and other data in documents – based on the assumption that these elements might remain constant from visit to visit. Clinicians also tend to copy paste information like medical histories and discharge summaries from previous patient notes to save time. The copy-paste functionality was designed to improve the ease and efficiency of clinical documentation, foster communication, and importantly, allow physicians to spend more time with patients. However, despite these benefits, the copy/paste function can pose risks to the integrity of the medical record. Potential risks include:
- Copying and pasting information that is inaccurate or outdated
- Superfluous information in the EHR, which makes identifying current information a challenge
- Not being able to identify the author or intent of the documentation
- Inability to identify when the documentation was created
- Propagation of incorrect information – errors may be repeated in the record for months and even years
- Inconsistent progress notes
- Note bloat or progress notes that are too lengthy, making it difficult for future members of the care team to analyze the details of a patient’s medical care
Inappropriate use of copy/paste could also lead to reimbursement fraud. If too much of information is pulled from a previous note with properly reviewing it, physicians may end up unintentionally documenting services that were completed during an earlier visit, raising questions of misrepresentation or even fraud. A survey by the Medical Professional Liability Association identified copy and paste as the main factor in EHR-related malpractice allegations, and a claims data analysis enabled by CRICO Strategies also reported that copy and paste is a key user error contributing to malpractice lawsuits (www.medpro.com).
So, what’s the way out? Is it to disable the copy-paste function? No, say experts.
“There’s no question that copy-and-paste can be misused or overused, but it’s also a helpful function for reducing burden when it’s appropriately used, says Dr. Christopher Longhurst, chief information officer at UC San Diego Health. “There’s a place for it, and turning it off completely is not helpful.” (www.modernhealthcare.com).
Measures for Safe Use of Copying and Pasting
Steps that physicians can take to promote safe use of copy-paste, including recommendations from the American Health Information Management Association:
- Establishing policies on where copy-paste can be used and where it cannot to assure compliance with governmental, regulatory and industry standards.
- Address copy-and-paste utilization in the organization’s information governance processes and monitor physician adherence to the policies.
- Encouraging physicians to adequately edit the copy-pasted information to ensure it is still up-to-date and relevant for the patient’s current care.
- Train and educate all EHR system users on proper use of copy-and-paste.
- Establish corrective action as needed.
Structured entries are required in EHRs for demographics, vital signs, smoking status, problem list, medication list, medication allergies, lab tests/values, and at least one family history entry. According to Medical Economics, one report, up to 91% to 93% of data entered in structured forms can be captured via dictation, transcription, and free-text entry.
The Bottom Line: Since appropriate use of the copy-paste function is crucial for patient safety and documentation integrity, physicians should use this EHR feature with caution. Medical transcription services can help with EHR documentation, allowing providers to focus on the patient during the office visit. With EHR voice-recognition software, physicians can directly dictate into the system and have the automated notes reviewed for accuracy by an experienced medical transcription service provider.