The electronic health record (EHR) has been beneficial to both healthcare providers and patients. Healthcare providers can easily access patient records from consultants, hospitals and other healthcare facilities. Patients have direct access to their medical records through patient portals. However, one concern for healthcare providers when using the EHR is the “copy and paste” function.
The electronic copy and paste function is a major problem in healthcare. A study published in JAMA Network Open in September 2022 found that half of the medical records reviewed as part of the study contained duplicative information from prior documentation. The study revealed that physicians, nurses and therapists routinely use the copy and paste function in the EHR.
This blog will discuss some of the risks to consider when using the copy and paste function.
Concerns with the Use of Copy and Paste in the EHR
One of the biggest concerns is that information from a prior visit may no longer be accurate, current or relevant. Outdated information will affect formulation of a proper diagnosis. Documentation should always reflect care and decision-making made during that specific visit.
Providers should be mindful when copying information from portions of the EHR, such as medication lists, treatment notes and histories. If this information is not current or accurate, it could appear that the patient’s condition has not changed and may result in a wrong diagnosis or treatment plan. When medication lists are copied and pasted without reconciliation, significant medication errors impacting the patient’s health may occur.
In addition to inaccurate or outdated information, excessive use of copy and paste may reflect a higher level of service than was provided. This could place the healthcare provider at risk for allegations of insurance fraud.
Further, copy and paste issues have been seen as a contributing factor in medical malpractice cases. According to CRICO, when there is an allegation regarding copy and paste, more cases are closed with payment than without. A study by CRICO’s Candello division found that over a five-year period, malpractice cases with an EHR user issue closed with payment to the plaintiff about 23 percent more often than cases without an EHR user issue. Cases that included a copy and paste allegation were about 18 percent more likely to close with payment than other EHR cases.
Tips to Reduce Risks Associated with Using Copy and Paste in the EHR
To reduce the risks associated with the copy and paste function in the EHR, MLMIC recommends the following:
- Develop a comprehensive policy and procedure for the appropriate use of the copy and paste function. The policy should include a process to monitor and audit both the staff and providers’ use of this function.
- Educate all EHR users about:
- the importance of verifying that the copied and pasted information is correct and accurately describes the patient’s current condition;
- the risk to patient safety in the inappropriate use of this function; and
- the importance of adhering to all regulatory, legal, and compliance guidelines.
- Determine what portions of the record may be copied and pasted. At a minimum, the healthcare provider’s signature(s) should not be copied and pasted.
- Confirm that the source of the information which has been copied and pasted can be readily identified and is available for review in the future.
- Confirm that the history of present illness is based upon the patient’s description during that visit.
- Use the medical, social or family history from a previous note only after it has been reviewed with the patient to confirm it is current.
- Verify that the diagnoses in your assessment are only those addressed at that visit. Although some EHRs allow the copying of all diagnoses in the problem list, some may either have already been resolved or they are not the reason for this particular encounter.
- Contact your EHR vendor as necessary to help you and your staff comply with established policies. This may include the vendor making modifications which disable the copy and paste function in designated fields and assisting in performing audits of the use of the copy and paste function by staff and providers.
MLMIC has created several educational programs regarding documentation, as well as a “Reducing the Risk of the Copy and Paste Function in Electronic Health Records” Checklist. MLMIC policyholders can obtain a copy of the checklist by reaching out to their Risk Management Consultant or contacting Matthew Lamb, Esq. at mlamb@mlmic.com.
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