What should be considered when deciding whether or not to use the copy paste functionality?

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Update July 2021

Issue:

The use of the copy-and-paste function (CPF) in health care provider’s clinical documentation improves efficiencies, however CPF can promote note bloat, internal inconsistencies, error propagation, and documentation in the wrong patient chart,1 potentially putting patients at risk. A workgroup convened by the Partnership for Health IT Patient Safety conducted a literature review that 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.

The workgroup found several case reports of 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. Two years prior, the patient was discharged from the emergency department after a new diagnosis of atrial fibrillation and potential heart disease; he was instructed to follow up with his PCP for a stress test. 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. The PCP was found liable in the death.1

Safety Actions to Consider:

All organizations that use EHRs should be aware of the potential risks of the CPF and collaborate with their health care providers to ensure this tool does not lead to unintended consequences that may result in patient harm. There are actions that health care organizations can take to help prevent copy-and-paste errors in EHRs, including the following recommendations from the Partnership for Health IT Patient Safety workgroup and the American Health Information Management Association:

• Provide a mechanism to make copy-and-paste material easily identifiable. This enables the health care provider to review, confirm and validate the copied material. Some suggested modifications to make copied material more visible include altering font color, highlighting copied text, or linking between different documents. Note: This will require new software functionality.1
• Ensure that the provenance of copy-and-paste material is readily available. Having the source, context, author, time, and date of the source information facilitates the ability to verify the accuracy, applicability, reliability, and timeliness of the documentation. Information could be displayed by hover notification, a split screen, hypertext, or separate log files.1
• Ensure adequate staff training and education regarding the appropriate and safe use of CPF. Outlining proper procedures for copying and pasting information can standardize the process to ensure staff is following appropriate and best practice guidelines and facilitate regulatory compliance. Encourage users to avoid workarounds to bypass policy and technological limits placed on the copy-and-paste functionality.1
• Ensure that copy-and-paste practices are regularly monitored, measured, and assessed. Monitoring will help ensure that the identified solutions are appropriate and effective. Note: Such capabilities are likely to require software and potentially hardware modifications.1 Include a feedback loop to inform health care providers when their documentation is not accurate or is overly redundant.2
• Develop policies and procedures addressing the proper use of the CPF to assure compliance with governmental, regulatory and industry standards.2 Also provide clarity on what is permissible to copy, when CPF should never be allowed, and consequences for violations. The Partnership for Health IT Patient Safety workgroup solicited insights from experts who agreed that information should never be copied in certain contexts, including signature lines, copying between different charts, and any information that has not been read and edited.1
• Address the use of features such as copy and paste in the organization’s information governance processes.2
• Provide comprehensive training and education on proper use of copy and paste to all EHR system users.
• Monitor compliance and enforce policies and procedures regarding use of copy and paste, and institute corrective action as needed.2                                 

In addition, the following recommendations from The Joint Commission can further support the safe use of the CPF in EHRs:  

• Monitor compliance by beginning a focused and ongoing professional performance evaluation (OPPE) with specific triggers and measures related to the accuracy of the clinical record.
• Maintain robust quality review process(es) in which all cases of potential misuse or error due to CPF are evaluated consistently and comprehensively to identify opportunities for improvement in patient safety.

Resources:

1. Tsou AY, Lehmann CU, Michel J, et al. “Safe Practices for Copy and Paste in the EHR: Systematic Review, Recommendations, and Novel Model for Health IT Collaboration.” Applied Clinical Informatics, 2017;8:12-34.
2. American Health Information Management Association: “Appropriate Use of the Copy and Paste Functionality in Electronic Health Records.” AHIMA Position Statement (accessed February 10, 2015)

Additional resources:

Partnership for Health IT Patient Safety

Health IT Safe Practices: Toolkit for the Safe Use of Copy and Paste. February 2016. Includes implementation aids for organizations, including a training checklist, educational presentations, risk identification assessments (tailored for various stakeholders), self-assessment checklists, templates for policies and procedures, implementation plans and strategies for stakeholder groups, and audit and assessment tools which can be used to assess successful implementation.

Note: This is not an all-inclusive list.

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