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
- 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.
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