Copy and Paste: The unintended consequence of convenience

Copy and Paste, also known as cloning, appears to be a seemingly harmless convenience for busy clinicians. According to the America Health Information Management Association (AHIMA), 74 to 90 percent of physicians use the copy/paste feature when recording information in electronic health records (EHRs), and between 20 to 78 percent of physician notes are copied text (AHIMA report.) Clearly, many leverage this convenience that EHR software affords to busy clinicians.  But, is it a safe practice?

Over the past 10 years, I have heard EHR users hail the timesavings gained by using the copy and paste feature.  I have also seen egregious errors of all types introduced into a medical record by this same practice, including, for example, a situation where an original wound assessment was copied forward for every reassessment so that it appeared that the patient’s wound never improved or healed. Another witnessed example of copy/paste gone awry is where a patient’s historical family condition migrated to the patient’s active problem list and a consultant began treating a condition that was not present for this patient. I’m thinking you might also have observed unimaginable errors. My list of examples is long and my experiences have made me personally reluctant to activate the copy and paste feature within an EHR.  I have experienced this conversation many times with clinicians who argue that we should not punish them by withholding this timesaving convenience because of a few bad actors. The truth is, in my experience, these individuals are not bad actors; they are busy and caring professional clinicians that were set up to fail.  For that reason, I feel we, as specialists in the use of health information, need to implement systems that make it hard for the clinician to do the wrong thing and easy to do the right thing. Using copy/paste inappropriately can result – and has resulted – in redundancies and errors that impact safe patient care and, therefore, we need to proceed with caution.

AHIMA has been raising concerns about this practice for years and recently released an advisory notice on March 17, 2014 stating that the use of copy/paste should be permitted only when "strong technology and administrative controls” are in place.  This notice recommends specific steps for the following groups:

• Industry stakeholders
• EHR developers
• Public sector
• Healthcare provider organizations

In the end, there are no absolutes.  I believe that users of the copy/paste feature should weigh the efficiency and timesaving benefits it provides against the potential for creating inaccurate or misleading documentation that negatively impacts patient care. The following are the AHIMA recommendations for the healthcare provider organization:

• Develop policies/procedures addressing the proper use of the copy/paste feature to assure compliance with governmental, regulatory, and industry standards.
•  Address the use of features such as copy/paste in information governance processes.
•  Provide comprehensive training and education on proper use of copy/paste to all EHR system users.
• Monitor compliance and enforce policies/procedures regarding use of copy/paste and institute corrective action as necessary.

As informatics nurse specialists, we are ideal candidates to help healthcare provider organizations implement these recommendations.

To review the complete AHIMA advisory notice visit:

http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_050621.pdf

Vendor relationships require leadership

Vendor relationships require leadership

It is time to upgrade or replace existing information software.  The executive team has approved and funded the project. The purchase orders are issued and the vendor has assigned a “PM” (Project Manager) for your project. The next steps are to organize the project timeline and craft the details of the project plan.  As you work through this process you note that vendors have an advantage because they have a team of individuals that do only project management for this specific software implementation.  My experience has been that the vendor PM will often come in with the intent to lead the project, when in fact, the project is your responsibility.  The challenge becomes how to leverage the vendor’s expertise and experience in a cooperative way while maintaining your role as leader of the project.

I have found there is a range of ways you can maintain control of your project when the vendor PM attempts taken over. These strategies rely on leadership and management techniques; good communication skills; and the ability to influence others and articulate system requirements. Lastly, applying emotional intelligence (EI) to the situation is extremely helpful.  EI is the ability to read a situation, know the team members, know oneself, and respond accordingly. It is important to include the vendor as part of the team and solicit their input.  It is also important to present yourself as the project lead.

Remember that, in any relationship, heavy-handedness often comes with a price. Fixing issues and problems by issuing threats of additional penalties may work in dire situations with problem vendors, but is not a universally recommended mode for achieving a successful implementation.  Attributes that I believe support successful vendor relationships are: accessibility, candor, toughness, intensity, likability, humor, integrity, follow through, reputation, presentation, and clear communication.  I also find that using a blend of leadership and management techniques with communication and EI skills will support project success.  I have found these ten actions help:

1.   Have a clear vision of the outcomes, and communicate that vision so others can grasp it

2.   Focus communication to create understanding and clarity of the project expectations, roles, tasks, barriers and outcomes

3.   Apply EI to read situations, and personal strength to take a stand as needed

4.   Use abilities to connect and work with a range of people, professions and personal styles of communication

5.   Set and monitor deadlines and project timelines

6.   Work to  gain early and continuous buy-in from stakeholders  around project targets and goals

7.   Negotiate work agreements, assignments, and day-to-day issues resolution

8.   Articulate the plan and steps to others in a clear and concise manner with frequent updates

9.   Engage others in the process of problem resolution

10.    Be flexible and willing to adapt to changes while helping others to adapt to changes as well.

Whenever project management is required, whether for a small project or a large and complex situation certain key attributes and actions tend to be universally recommended to help achieve project success. I have found that, by tailoring one or more of these to the current effort, project steps are much smoother and project success is more likely to be realized. 

Nursing informatics: It is what we know that matters

In the 2008 ANA Scope and Standards, you will find NI defined as “ Nursing informatics (NI) integrates nursing science, computer and information science, and cognitive science to manage, communicate, and expand the data, information, knowledge, and wisdom of nursing practice. Nurses trained in NI support improved patient outcomes through their expertise in information processes, structures, and technologies, thus helping nurses and other care providers to create and record the evidence of their practice” (ANA, 2008).  As an Informatics Nurse Specialist (INS), I do much more than support patient outcomes through my expertise in information processes, structure, and technologies.  The industry has also recognized that it may be time to revise the current definition.  In the proposed revision, the definition evolves to “Nursing informatics (NI) is a specialty that integrates nursing science with multiple information management and analytical sciences to identify, define, manage, and communicate data, information, knowledge, and wisdom in nursing practice. NI supports consumers, patients, nurses, and other healthcare professionals in their decision-making in all roles and settings to achieve desired outcomes. This support is accomplished through the use of information structures, information processes, and information technology” (ANA, 2013).

This evolution fits with the concept of nurses as knowledge workers. As nurses, INSs do not simply have expertise in data and information processes.  Data capture, management, processing, retrieval, storage and the like are really our tools.  Just like any profession, the tools used do not define a person’s responsibility or contribution.  Rather, it is the outcome. In nursing, our contribution cannot be measured by how much data we capture or how we process it. It is how we use that data and what we learn from it that will move us forward.

For this reason, I think of INSs and nurses alike as being knowledge workers.   A Knowledge worker is someone who advances the overall understanding of a subject through focused analysis, design, and/or development (Tripathi, 2010). They use research skills to define problems and to identify alternatives. This process creates a culture of integrated knowledge management. As INSs, we provide information while thinking about clinical care delivery and ways to expand our knowing in nursing. We establish competencies and practice standards which we apply to nursing care delivery.  New technologies allow easier data capture and analysis. We leverage this to transform nursing practice through better sharing and management of knowledge at the point of care delivery and create a generation of new understanding about nurse’s contribution to clinical outcomes.  In short, it is what we know that matters.

Reference:

Tripathi, K. P. (2010). An Empirical Study of Managing Knowledge Workers. International journal of computer application 12:7 December 2010 Retrieved 1/25/13 from http://www.ijcaonline.org/volume12/number7/pxc3872255.pdf