Copy, Paste, and Cloned Notes in Electronic Health Records

doi:10.1378/chest.13-0886

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Volume 145, Issue 3, March 2014, Pages 632-638

https://doi.org/10.1378/chest.13-0886 Get rights and content

The modern medical record is not only used by providers to record nuances of patient care, but also is a document that must withstand the scrutiny of insurance payers and legal review. Medical documentation has evolved with the rapid growth in the use of electronic health records (EHRs). The medical software industry has created new tools and more efficient ways to document patient care encounters and record results of diagnostic testing. While these techniques have resulted in efficiencies and improvements in patient care and provider documentation, they have also created a host of new problems, including authorship attribution, data integrity, and regulatory concerns over the accuracy and medical necessity of billed services. Policies to guide provider documentation in EHRs have been developed by institutions and payers with the goal of reducing patient care risks as well as preventing fraud and abuse. In this article, we describe the major content-importing technologies that are commonly used in EHR documentation as well as the benefits and risks associated with their use. We have also reviewed a number of institutional policies and offer some best practice recommendations.

Section snippets

Methods of Importing Content in EHRs

Advances in computer technology have created multiple ways a provider may copy or generically import information from prior entries of the medical record (Table 1). While it is beyond the scope of this article to address in detail the specific mechanics and functionality of each company's CIT, we aim to describe in general terms the more common techniques available today. For more information, the reader is referred to specific EHR software companies.

The keyboard command Ctrl-C followed by

CIT: Benefits

EHRs have benefits for patients, physicians, and the broader community.³ Benefit may be realized through improved access to records facilitating communication, increased quality of care through clinical decision support and safety engineering, financial incentives, or potential gains in medical research and education. The benefits specifically attributable to CIT, however, have not been well studied. Even though EHRs have been linked to reductions in productivity, there is a general sense among

CITs: Prevalence and Risks

The body of literature assessing the prevalence and clinical impact of CIT has been building for > 10 years. An appropriate national conversation regarding its impact has lagged significantly. An in-depth review of 243 patients cared for within the Veterans Administration between 1993 and 2002 found 2,645 notes containing significant amounts of copied text: a 9% prevalence.⁵ The authors analyzed the type of information copied and the elapsed interval. Each instance was scored using a six-point

CITs: Patient Care Risks

While copy functionality can improve provider efficiency, there are also many potential risks to patient care (Table 3). Risks vary depending on the nature and extent of the copied material.8, 9 When the history of present illness or subjective symptoms are copied or imported, there is great concern whether the EHR accurately and succinctly describes the health status of the patient on the date and time of the encounter.¹⁰ Importation of allergy and medication lists that have not been reviewed

CITs: Regulatory Risks

Provider use of CIT has raised a number of regulatory concerns associated with hospital and professional billing, as well as reporting of quality data (Table 4).¹⁴ The ease in which medical records can be populated with clinical information has caused the Office of the Inspector General to question the medical necessity of the services billed.15, 16 For example, excessive documentation for what appears to be a minor clinical problem cannot be used to justify higher levels of hospital or

CITs: Policy Review

We reviewed policies and recommendations from several large health-care institutions, the Association of American Medical Colleges, and the American Health Information Management Association with respect to guiding providers in the use of CIT (Table 5). Core themes arose regarding the risks vs benefits of using these tools. Several policies advised against applying CIT to specific subsections of an evaluation and management service. Specifically, the history of present illness and the

Conclusions

EHRs are dramatically changing medical documentation. The multitude of methods to import clinical information has created new challenges for clinicians as well as payers. From a patient care perspective, clinicians need to ensure that using CIT enhances not only the documentation of patient care but also the quality of care. While judicious use of CIT can create efficiencies for the busy clinician, as well as improve the tracking of multiple problems on highly complex patients, indiscriminate

Acknowledgments

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

References (32)

DR Erickson
Paradoxical consequences and electronic notes
J Urol
(2013)
PJ Embi et al.
Impacts of computerized physician documentation in a teaching hospital: perceptions of faculty and resident physicians
J Am Med Inform Assoc
(2004)
J Horsky et al.
To err is not entirely human: complex technology and user cognition
J Biomed Inform
(2005)
JH Carter
What is the electronic health record?
(2008)
N Menachemi et al.
Benefits and drawbacks of electronic health record systems
Risk Manag Healthc Policy
(2011)
CR Weir et al.
Direct text entry in electronic progress notes. An evaluation of input errors
Methods Inf Med
(2003)
KW Hammond et al.
Are electronic medical records trustworthy? Observations on copying, pasting and duplication
AMIA Annu Symp Proc
(2003;2003)
JD Thornton et al.
Prevalence of copied information by attendings and residents in critical care progress notes
Crit Care Med
(2013)
HC O'Donnell et al.
Physicians' attitudes towards copy and pasting in electronic note writing
J Gen Intern Med
(2009)

RE Hirschtick

A piece of my mind. John Lennon's elbow

JAMA

(2012)

H Singh et al.

Types and origins of diagnostic errors in primary care settings

JAMA Intern Med

(2013)

GD Schiff et al.

Can electronic clinical documentation help prevent diagnostic errors?

N Engl J Med

(2010)

Guidelines for EHR documentation to prevent fraud

J AHIMA

(2007)

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Topics in Practice ManagementCopy, Paste, and Cloned Notes in Electronic Health Records

Section snippets

Methods of Importing Content in EHRs

CIT: Benefits

CITs: Prevalence and Risks

CITs: Patient Care Risks

CITs: Regulatory Risks

CITs: Policy Review

Conclusions

Acknowledgments

J Urol

J Am Med Inform Assoc

J Biomed Inform

What is the electronic health record?

Benefits and drawbacks of electronic health record systems

Risk Manag Healthc Policy

Direct text entry in electronic progress notes. An evaluation of input errors

Methods Inf Med

Are electronic medical records trustworthy? Observations on copying, pasting and duplication

AMIA Annu Symp Proc

Prevalence of copied information by attendings and residents in critical care progress notes

Crit Care Med

Physicians' attitudes towards copy and pasting in electronic note writing

J Gen Intern Med