Why is copying and pasting in the EHR such a problem?

Robert A. Dowling, MD, writes, "Although ostensibly a time saver, [copying and pasting] may lead to inaccuracies, scattered information and information overload, mistakes in care, and physician burnout."

As many as 90% of clinicians report using copy-and-paste functionality when documenting in the electronic health record (EHR), 81% admit to frequently copying other author’s notes, and 25% agree that the practice leads to mistakes in patient care.¹ Several papers have been published documenting and quantifying the copy-and-paste problem by analyzing progress notes for redundancy.² Professional organizations and patient safety organizations have issued statements and best practices on this behavior to prevent harm.^3,4 Many believe that the notes generated by copying and pasting are a direct and significant source of physician burnout. In this article, I will summarize some of these findings and discuss how you—the practicing urologist—can limit your use of this behavior, improve patient safety, make your patient documentation more readable and meaningful, and perhaps even reduce burnout.

What is the problem? Some younger readers may have never known a medical record that was notelectronic or a progress note that was not mostly copied forward from a previous visit. But there was a time not long ago when charts were on paper, every visit was a separate document, and the record was organized by category and time. The progress note was just an interim recording of the patient’s progress. It was uncommon that a progress note was long, copied forward verbatim from a previous visit, or a complete summary of the patient. Physicians were adept at flipping quickly to key parts of the record to gain or regain their clinical impressions. Seeking to please their users, EHR developers attempted to replicate a paper chart in a computable format. At nearly the same time, insurance-driven documentation requirements for reimbursement became more complex and onerous. One user adaptation to meet these requirements was to bloat the progress note with information intended primarily to meet coding requirements and then copy it forward at every visit, often without editing or deleting old and outdated content. These habits have hardened and shaped the contemporary record. As new content is added, notes become increasingly long and redundant. Information overload obscures relevant information, wastes physician time during review, generates inaccurate data (in turn rendering data-driven quality efforts moot), and leads to errors.² Copying and pasting is not a benign user adaptation.

How widespread is the problem? A recent analysis of over 100 million notes in a single health system revealed that 50% of note content was copied verbatim from a previous note.² Fifty-four percent of the copied content came from the same author, meaning 46% of the copied content came from a differentauthor. The findings were consistent across care settings (eg, inpatient and ambulatory) and author types (eg, role and specialty). In a famous anecdote,⁵ an emergency department physician seeing a patient with chest pain noted the EHR referenced a “PE.” The physician explained why he was ordering a CT scan to rule out pulmonary embolism, only to have the patient deny a history of this condition or taking blood thinners. Upon review, the PE referred to a physical exam but had been transcribed and perpetuated by multiple authors in the patient history as a pulmonary embolism. The potential for perpetuating incomplete or inaccurate information is clear, especially as documentation becomes collaborative and authors copy other authors. In the education setting, a patient record may have contributions from medical students, residents, fellows, and attending physicians. In the urology office, the progress note may be a compilation of documentation from scribes, advanced practice providers, and physicians. Copying and pasting saves time but comes with significant risk of creating an unwieldy, unreadable, and inaccurate record.

What are the root causes of the problem? Although coding requirements for reimbursement are a significant incentive for bloating the note, many believe the note paradigm itself is to blame. The contemporary EHR is an information management system with powerful tools for visualization, interoperability, and decision support. However, many users think of the EHR primarily as a progress note generator. A common practice is to use the note as a reservoir of the entire chart in the belief that this is an easy and efficient way to summarize the patient’s conditions and status. Other factors contributing to bloated, redundant notes could include a lack of EHR training, incomplete or failed implementation (including but not limited to underused favorites, problem lists, and macros), or even a faulty EHR design. The note paradigm incentivizes the use of copying and pasting but does not meet the contemporary needs of information storage, retrieval, and management or team care.

What can be done about the problem? New evaluation and management guidelines should reduce the incentive to include old information simply to justify coding levels. Some EHR vendors have already created tools that display content copied in a different style than original content, making it easier to see what is new and what is old. One possible solution is already included in most EHRs but, in this author’s opinion, is vastly underused: the problem list. Many problem lists allow dynamic documentation with a wiki model—information that can be edited but is stored and available independent of any individual note (much like a medication list). For example, the problem prostate cancer may have some discrete attributes (eg, stage or grade) that can be updated as needed, but the problem list allows narrative comments that remain associated (not copied each time) with the problem until it is edited (eg, treatment dates). Reviewing the problem list is usually simpler and easier than scanning a bloated, redundant note. Many systems allow the automatic citation of the problem and its attributes in the progress note. For those married to the note paradigm, reordering the content—sometimes called the assessment, plan, subjective, objective note—may make it more efficient to review relevant information by pushing redundant information to the bottom. Finally, sharing notes with patients is now a reality and a mandate that will help providers be accountable for creating readable, accurate notes.

The bottom line and why it matters

Copying and pasting is an understandable adaptation when using a computer primarily for sequential progress notes. Although ostensibly a time saver, it may lead to inaccuracies, scattered information and information overload, mistakes in care, and physician burnout. Until new systems are designed to extend the wiki model and reduce the primacy of the progress note to document clinical care, physicians need to use copying and pasting responsibly and consider alternate time-saving strategies for documentation.

References

1. Tsou AY, Lehmann CU, Michel J, Solomon R, Possanza L, Gandhi T. Safe practices for copy and paste in the EHR. Systematic review, recommendations, and novel model for Health IT collaboration. Appl Clin Inform. 2017;8(1):12-34. doi:10.4338/ACI-2016-09-R-0150

2. Steinkamp J, Kantrowitz JJ, Airan-Javia S. Prevalence and sources of duplicate information in the electronic medical record. JAMA Netw Open. 2022;5(9):e2233348. doi:10.1001/jamanetworkopen.2022.33348

3. Dean SM. EHR copy and paste and patient safety. Patient Safety Network. January 1, 2018. Accessed October 3, 2022. https://bit.ly/3ynTp9Q

4. Appropriate use of the copy and paste functionality in electronic health records. American Health Information Management Association. Accessed October 3, 2022. https://bit.ly/3T0AV72

5. Hirschtick R. Sloppy and paste. Patient Safety Network. July 1, 2012. Accessed October 3, 2022. https://bit.ly/3EpP6yl