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Patient Safety Tip of the Week
August 29, 2023 The Perils of Copy and Paste
Copy and paste. Yes,
we all do it. In fact, we are doing it much more frequently. A recent study
looking at “bloat” in the electronic medical record (EMR) found that the size
of clinicians’ notes increased 8.1% from 2020 to 2023 (Bartelt
2023). Yet, they reduced
their average time of 5.4 minutes spent on each note to 4.8 minutes per note
during the same period. So, how did they do that? They found that organizations which increased note length saw increased use of copy/paste functions. Also, a previous study on over 100
million notes in the EMR from the University of Pennsylvania Medical Center (Steinkamp
2022) found that more than half of the text was duplicated. Duplicate
content was prevalent in notes written by physicians at all levels of training,
nurses, and therapists and was evenly divided between intra-author and
inter-author duplication. The duplication fraction increased year-over-year,
from 33.0% for notes written in 2015 to 54.2% for notes written in 2020. Of the
text duplicated, 54.1% came from text written by the same author, whereas 45.9%
was duplicated from a different author. Records with more notes had more total
duplicate text, approaching 60%.
Our September 15, 2009 Patient Safety Tip of the Week “ETTO’s:
Efficiency-Thoroughness Trade-Offs” discussed efficiency-thoroughness trade-offs or ETTO’s. That concept,
best associated with Erik Hollnagel (Hollnagel
2009), is well
known to everyone in the human factors and safety fields. Basically, the ETTO
concept means there are certain procedures and practices that we do which make
our work more efficient but at the risk we may compromise thoroughness or
safety. Hollnagel, in his book, notes that such
things usually go right but occasionally go wrong. A classic example of an ETTO
is the “copy and paste” function that we all know well from our word processors
and spread sheets. Copy and paste functionality is also widely used in
electronic medical records. It allows us to easily input a large amount of
text, images, etc. into one part of an EHR without having to type in all the
details. This can be a huge timesaver.
But there are times
when “copy and paste” can go wrong. While copy & paste may improve
efficiency of clinicians, it is a patient safety issue because it increases the
likelihood of erroneous information that may negatively impact a patient’s
care. Several of our columns have noted that copy/paste led to patients being
continued or restarted on medications that had actually been
discontinued.
We know of no
comprehensive study on the adverse consequences of copy & paste. Most
examples come from individual case studies or anecdotal reports. In a study of
diagnostic errors in primary care in the VA health system, Singh et al. (Singh
2013) noted that practitioners
copied and pasted previous progress notes into the index visit note in 7.4% of
cases and, of these cases, copying and pasting mistakes were determined to
contribute to more than one-third (35.7%) of errors.
Our February 28, 2017 Patient Safety Tip of the Week “The
Copy and Paste ETTO”
reminds us how the copy/paste function in today’s healthcare IT systems can
lead to erroneous medication lists that might result in a patient being
inappropriately restarted on a medication that had actually been discontinued.
In our September 24, 2019 Patient
Safety Tip of the Week “EHR-related
Malpractice Claims” we noted that copy & paste errors often led to
medication errors, sometimes copying over a medication that had been
discontinued since the prior note, and sometimes failing to include a
medication that had been started since the prior note.
In a more recent column (August 15, 2023 Patient Safety Tip
of the Week “Problems
with Newer Diabetes Drugs”) we noted that ISMP Canada (ISMP
Canada 2023) found the “copy and paste” issue to be problematic because frequent
adjustments of diabetes drugs are common. These may include dose modifications,
addition of an agent from a different medication class, or a switch in medications.
A pharmacist or a prescriber may copy a prior order, intending to alter the
dose after pasting into a new order but then forgetting to make that change.
ISMP Canada therefore recommends limiting the “copy” function to prescriptions
that are unchanged from the previous prescriptions.
There are also instances where an inaccurate piece of
information may get deleted (or more properly amended with appropriate attribution)
from the medical record but someone copies and pastes that item from a prior
part of the medical record, thus perpetuating the erroneous information. A good
example is when the record says a patient is allergic to a certain antibiotic
but that later gets amended when a physician realizes there was no true
allergy. If the original note noting the “allergy” gets copied and pasted, the
patient may be deprived of a most appropriate antibiotic in the future.
Sandeep Jauhar (Jauhar
2023) recently wrote that he took care of a patient whose medical records
included multiple notes about her past open-heart surgery. The only problem was
that she had never undergone open-heart surgery! He notes that would have been
obvious if the authors of those notes “had taken the time to notice that she
had no scars on her chest or breastbone. She was being prepared for an invasive
procedure based on this misinformation when the true facts of her condition
were revealed and the procedure canceled — though by then the false information
had virally propagated through the chart and into multiple notes, becoming
“chart lore.”
Hersh (Hersh
2007) described a case of a woman with cancer and a history of pulmonary
embolism following hip surgery. She was admitted for diarrhea and dehydration
after completing her fifth cycle of chemotherapy for ovarian cancer and was
given intravenous fluids. The intern's admitting note
also stated that the patient would receive subcutaneous heparin for venous
thromboembolism (VTE) prophylaxis, although this was never actually ordered. The
patient's care was transferred to a different team the following day, and the
accepting intern copied and pasted the plans of the admitting intern into the
new note within the electronic health record (EHR). The same note was then
copied and pasted on 4 consecutive hospital days and cosigned by the resident
and attending, and the patient was ultimately discharged having never received
the intended VTE prophylaxis—despite each day's note stating this as part of
the plan. Two days following discharge, the patient developed acute shortness
of breath and hypoxia and returned to the hospital, where she was diagnosed
with a pulmonary embolus. Only at this admission, and after careful review of
the medication record from the previous hospitalization, was it realized that
the patient never received any VTE prophylaxis.
Hersh appropriately notes that copying and pasting of
patient information has probably been occurring since the beginning of recorded
medical information. It’s just that EHR’s make copying and pasting very easy. He stresses that, when copying and pasting is
done, the physician should be careful to attribute the source and to check that
the information being pasted is not erroneous or out of date.
CRICO, the medical malpractice insurance carrier, notes “Overall,
copy and paste as a contributing factor in a malpractice case is rare. However,
when it does come up in a case, it tends to be a factor in which we close more
of those cases with payment than without it.” (CRICO 2023).
CRICO found that, over a recent five-year period, malpractice cases with an
electronic health record user issue closed with a payment to the plaintiff
about 23 percent more often than cases without an EHR user issue. And the ones
that feature copy and paste issues are about 18 percent more likely to close
with payment than other EHR cases.
The copy & paste issue also
caught the attention of the Joint Commission. The Joint Commission (TJC 2021) notes that
“use of the copy-and-paste function (CPF) in health care provider’s clinical
documentation improves efficiencies, however CPF can promote note bloat,
internal inconsistencies, error propagation, and documentation in the wrong
patient chart, potentially putting patients at risk.”
A workgroup convened by the
Partnership for Health IT Patient Safety conducted a literature review that
identified 51 publications; one study of diagnostic errors found that CPF led
to 2.6% of errors in which a missed diagnosis required patients to seek
additional unplanned care. The workgroup found several case reports of clinical
harm related to CPF, including a patient who died from a heart attack after his
primary care physician failed to diagnose cardiac disease. Two years prior, the
patient was discharged from the emergency department after a new diagnosis of
atrial fibrillation and potential heart disease; he was instructed to follow up
with his PCP for a stress test. The PCP copied and pasted the Assessment and
Plan (A/P) section of the patient’s record for 12 office visits during the next
two years, updating the A/P or reviewing medical entries from the ED or other
department. The PCP was found liable in the death.
The Joint Commission identified several Safety Actions to
consider:
All organizations that use EHRs
should be aware of the potential risks of the CPF and collaborate with their
health care providers to ensure this tool does not lead to unintended
consequences that may result in patient harm. There are actions that health
care organizations can take to help prevent copy-and-paste errors in EHRs,
including the following recommendations from the Partnership for Health IT
Patient Safety workgroup and the American Health Information Management
Association:
·
Provide a mechanism to make copy-and-paste
material easily identifiable. This enables the health care provider to review,
confirm and validate the copied material. Some suggested modifications to make
copied material more visible include altering font color, highlighting copied
text, or linking between different documents. Note: This will require new
software functionality.
·
Ensure that the provenance of copy-and-paste
material is readily available. Having the source, context, author, time, and
date of the source information facilitates the ability to verify the accuracy,
applicability, reliability, and timeliness of the documentation. Information
could be displayed by hover notification, a split screen, hypertext, or
separate log files.
·
Ensure adequate staff training and education
regarding the appropriate and safe use of CPF. Outlining proper procedures for
copying and pasting information can standardize the process to ensure staff is
following appropriate and best practice guidelines and facilitate regulatory
compliance. Encourage users to avoid workarounds to bypass policy and
technological limits placed on the copy-and-paste functionality.
·
Ensure that copy-and-paste practices are
regularly monitored, measured, and assessed. Monitoring will help ensure that
the identified solutions are appropriate and effective. Note: Such capabilities
are likely to require software and potentially hardware modifications. Include
a feedback loop to inform health care providers when their documentation is not
accurate or is overly redundant.
·
Develop policies and procedures addressing the
proper use of the CPF to assure compliance with governmental, regulatory and
industry standards. Also provide clarity on what is permissible to copy,
when CPF should never be allowed, and consequences for violations. The
Partnership for Health IT Patient Safety workgroup solicited insights from
experts who agreed that information should never be copied in certain contexts,
including signature lines, copying between different charts, and any
information that has not been read and edited.
·
Address the use of features such as copy and
paste in the organization’s information governance processes.
·
Provide comprehensive training and education on
proper use of copy and paste to all EHR system users.
·
Monitor compliance and enforce policies and
procedures regarding use of copy and paste, and institute corrective action as
needed.
In addition, the following
recommendations from The Joint Commission can further support the safe use of
the CPF in EHRs:
·
Monitor compliance by beginning a focused and
ongoing professional performance evaluation (OPPE) with specific triggers and
measures related to the accuracy of the clinical record.
·
Maintain robust quality review process(es) in
which all cases of potential misuse or error due to CPF are evaluated consistently
and comprehensively to identify opportunities for improvement in patient
safety.
ECRI (ECRI 2015)
did a nice job of trying to determine the frequency of copy and paste in the
EHR. They note that reported rates vary depending upon the definitions used,
the venue, and the method used to detect copy and paste, but probably 90% of
physicians use copy & past in the EMR. The ECRI study also found that
nearly all aspects of the medical note have been subject to copy/paste,
including chief complaint, history of present illness, past medical history,
review of systems, physical exam, medications, lab and radiology results,
assessment, plan, etc.
The ECRI study noted four problems
arising from copy & paste:
·
Introduction of new inaccuracies, including
wrong patient/patient identification errors
·
Propagation of inaccurate information
·
Internal inconsistency of notes and information
·
Note “bloat”
The ECRI study has numerous
recommendations, including:
·
Authors of notes must be able to vouch for the
information’s accuracy, whether they have copied their own note or someone else’s
·
Acknowledgement of or attribution to the
original source of the information (particularly when copying from someone else)
·
Strive for brevity
·
Recognize that copy/paste may
acceptable for certain portions of the note, but perhaps forbidden for others.
Some items that should not be copied include medical student
notes or the history of present illness. Also not to
be copied from another provider’s notes are history of present illness, review
of systems, physical examination, assessment, and plan. But some sections such
as past medical history, family history, and social history might be amenable
to a “copy-forward” approach with modifications after the author confirmed the
accuracy with the patient.
We would even challenge the concept that copy & paste
increases efficiency. Yes, it certainly saves time for the person entering the
data. But, as pointed out by Steinkamp et al. (Steinkamp
2022), it “increases the time required for the reading clinician
attempting to discern which information is accurate and timely vs false or
irrelevant. Overworked clinicians may be disincentivized from reading such a bloated
record, missing valuable clinical context not easily found elsewhere (eg, reasons for past diagnostic or therapeutic decisions),
and leading to wasted time repeating past interventions or directly causing
patient harm by missing findings requiring follow-up.” They further note that rampant
duplication creates viral copies of errata that can spread through a record
until they are impossible to correct because of the number of copies and the
inability to mark information as erroneous.
Quite frankly, the copy & paste issue is a good reason
that patients should review their own electronic medical records. We don’t
doubt that a not insignificant portion of them may find erroneous information
in their records that originated from copy & paste errors.
So, what are the potential solutions? Complete
elimination of the copy & paste function is not a practical option, nor a
desirable one. Another would be to flag any copy & paste attempt with a
message telling the user to verify the content. That is also not practical,
since it undoubtedly would lead to alert fatigue.
Any solution is likely to come from the artificial intelligence
(AI) realm. In fact, a study from China (Cheng 2022)
successfully restricted use of copy and paste in the EMR. They used electronic
tools to detect word template similarities between clinical notes to identify
those copied and pasted from previous visit notes. After developing an institutional
policy, they set a threshold for determining whether a progress note was copied
and pasted at 70% similarity to previous documents (using natural language
programming and text mining) to determine the similarity. If the similarity was
more than 70%, the computer would not save the progress note, similar to a plagiarism detection checker.
The prevalence of copying and pasting was significantly
reduced, from 35.72 ± 5.53% to 23.71 ± 6.9% (P = .001),
after monitoring. The prevalence of copying and pasting initially showed a
decreasing trend for 11 months, followed by a short period of a
significantly increasing trend and then stability after the restriction of
copying and pasting.
The 14-day readmission rate, length of stay and inpatient
mortality rate were evaluated to measure healthcare quality. The overall rate
of readmission for the same disease within 14 days was reduced from
3.46 ± 0.43% to 1.5 ± 1.03% (P < .001).
The rate of discharge summary note completion within 3 days decreased
from 93.73 ± 1.39% to 91.77 ± 1.67% (P = .011)
after monitoring. However, the length of stay and inpatient mortality were not
significantly different. The rate of readmission for the same disease within
14 days was found to be related to the prevalence of copying and pasting
in our study, with a 1-month lag.
We’d have likely chosen much different quality indicators to
track (eg. number of times an incorrect medication appeared
in notes), measures of “bloat” (eg. average note
size), measures of efficiency (time to note completion), and some measure of
clinician satisfaction.
But the key point here is that there was an effective way to
restrict use of the copy & paste function. They basically found that the
prevalence of copied-and-pasted text was about 40% before the restriction and
decreased to less than 20% each year after the restriction policy was
implemented. We’ll leave it up to the IT experts to figure out ways we can use natural
language programming, text mining, and artificial intelligence to reduce
overall use of copy & paste in the EMR.
*The author of today’s column (BTT) acknowledges that copy & paste undoubtedly contributed to “column bloat”. Thank goodness this is not a note in an EMR!!!!
References:
Bartelt K, Joyce B, McCaffrey K, Butler
S, Deckert J, Gates C. Two Years After Coding Changes
Sought to Decrease Documentation, Notes Remain ‘Bloated’. Epic Research 2023; July
6, 2023
Steinkamp J, Kantrowitz
JJ, Airan-Javia S. Prevalence and Sources of
Duplicate Information in the Electronic Medical Record. JAMA Netw Open 2022; 5(9): e2233348
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2796664
Hollnagel E. The ETTO Principle:
Efficiency-Thoroughness Trade-Off. Why Things That Go Right Sometimes Go Wrong.
Burlington, VT: Ashgate Publishing Company, 2009
Singh H, Giardina TD, Meyer AND, et al. Types and Origins of
Diagnostic Errors in Primary Care Settings. JAMA Intern Med 2013; 173(6): 418-425
published online February 25, 2013
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1656540
ISMP Canada. Newer Classes of Medications for Diabetes
Treatment: A Multi-Incident Analysis of Reports from the Community Pharmacy
Setting. ISMP Canada Safety Bulletin 2023; 23(4): April 26, 2203
Jauhar S. Bloated patient records are filled with false
information, thanks to copy-paste. Statnews.com 2023; June 20, 2023
https://www.statnews.com/2023/06/20/medical-records-errors-copy-paste/
Hersh W. Copy and Paste. AHRQ PSNet
WebM&M: Case Studies 2007; August 21, 2007
https://psnet.ahrq.gov/web-mm/copy-and-paste
Augello T. Copy and
Paste in the Medical Record: A Top EHR Danger (podcast). CRICO 2023; Feb 14,
2023
https://www.rmf.harvard.edu/Podcasts/2023/Copy-and-Paste-Risk
The Joint Commission. Quick Safety 10: Preventing
copy-and-paste errors in EHRs. The Joint Commission 2021; Update July 2021
ECRI Institute. Copy/Paste: Prevalence, Problems, and Best
Practices. Health Technology Assessment Information Service Special Report.
ECRI Institute 2015; October 2015
https://www.ecri.org/Resources/HIT/HTAIS_Copy_Paste_Report.pdf
Cheng CG, Wu DC, Lu JC, Yu CP, Lin HL, Wang MC, Cheng CA.
Restricted use of copy and paste in electronic health records potentially
improves healthcare quality. Medicine (Baltimore). 2022;101(4): e28644
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8797538/
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