Tag documentation

When reviewing content from the electronic health record (EHR), there are many elements to assess.  One of the elements is the use of the copy/paste functionality (CPF).  In this blog, I’ll be reviewing the use of CPF within the EHR.  I’ll also will be reviewing The American Health Information Management Association’s (AHIMA) position on the use of CPF, statistics, and risks associated with CPF.  I will conclude with reviewing the role of the medical legal consultant, as well as best practice recommendations to mitigate documentation risk. 

Use of the Copy/Paste Functionality (CPF) in EHR’s: The American Health Information Management Association (AHIMA) maintains the position that “the use of copy/paste functionality in EHRs should be permitted only in the presence of strong technical, and administrative controls, which include organizational policies, and procedures, requirements for participation in user training and education, and ongoing monitoring.  Users of the copy/paste functionality should weigh the efficiency and time savings benefits it provides against the potential for creating inaccurate, fraudulent or unwieldy documentation.”

CPF – A Common Occurrence in the EHR: The use of CPF continues to be a common occurrence which can lead to adverse outcomes. 

The Joint Commission published the results of the Partnership for Health IT Patient Safety work group.  Their literature review 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.

• Several case reports identified clinical harm related to CPF, including a patient who died from a heart attack after his primary care physician (PCP) failed to diagnose cardiac disease.

A. Two years prior, the patient was discharged from the ED after a new diagnosis of atrial fibrillation, and potential heart disease; he was instructed to follow up with his PCP for a stress test.

B.  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.

C.  The PCP was found liable in the death.

• A study published in 2017 reviewed inpatient progress notes written in 2016 by direct care hospitals, residents, and medical students totaling 23,630 notes by 460 clinicians.  In a typical note, 18% of the text was manually entered, 46% copied, and 36% imported.

Risks of CPF:

• Inaccurate or outdated information can lead to medical errors.
• Redundant information, which makes it difficult to identify the current information.
• Inability to identify the author or intent of documentation.
• Inability to identify when the documentation was first created.
• Propagation of false information: inflates, duplicates or creates fraudulent healthcare claims.
• Internally inconsistent progress notes.
• Unnecessarily lengthy progress notes.

Role of the Medical Legal Consultant:

Attorney-Client Education

• EHR documentation standards
• Discoverable items not included in the designated record set
• Regulatory requirements: user specific

Development of interrogatories & requests for production

Development of discovery responses

Recommend expert witnesses – specific to the EHR at issue

Witness Preparation

Educate staff/end users of the EHR

• Assess knowledge of the workflow
• Evaluate if end users have observed the native EHR in printed format
  A. Determine if they know how to read the printed version
• Types of assessments
  A. Standardized by EHR platform
  B. Customized by provider
  C. Use of free text

Evaluate the type of, and how much training the end user received prior to
using the EHR.  Evaluate what the training consisted of

Evaluate if the organization has consistency across EHR user roles,
access and permissions

Evaluate the organizations processes specific to record set-up, changes, revisions, additions,
and retirement of modules to the EHR

Ways to Mitigate Risk / Joint Commission Best Practice Recommendations:

• Chart timely: during the same scheduled shift
• Limit use of copy/paste functionality
• Be cognizant of scope of practice
• Disable drafts
• Utilization of the EHR report feature to track, trend, and audit. Ensure that copy/paste practices are regularly monitored, measured, and assessed
• Provide a mechanism to make copy/paste material easily identifiable
• Ensure adequate staff training, and education regarding the appropriate, and safe use of CPF
• Develop policies, and procedures addressing the proper use of the CPF to assure compliance with governmental, regulatory, and industry standards
• Address the use of features such as copy/paste in the organization’s information governance processes
• Monitor compliance, and enforce policies, and procedures regarding use of copy/paste, and institute corrective action as needed.

Resources:

The Joint Commission. Sentinel Event Alert 54. “Safe Use of Health
Information Technology.” March 31, 2015. Retrieved from: https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel-event-alert-newsletters/sentinel-event-alert-54-safe-use-of-health-information/#.YpkLlFTMIos

The Joint Commission. “The Joint Commission Standards.” https://www.jointcommission.org/standards

The Joint Commission. Quick Safety 10. “Preventing Copy-and-
Paste Errors in EHRs.” Updated July 2021. Retrieved from: https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety–issue-10-preventing-copy-and-paste-errors-in-ehrs/preventing-copyandpaste-errors-in-ehrs/#.YpkLcFTMIos

P.S. Comment and share – How will this information change your documentation practices, or how you analyze the EHR?