Shortcut key strokes could prove deadly with health records

Ctrl+C & Cltrl+V: They're better known as "copy-and-paste."

They are frequently used keystrokes that are supposed to offer a quick and easy way to replicate text. But careless copying and pasting could to lead to deadly errors in the healthcare industry and unfortunately, some of those mistakes may be flying under the radar.

Over the past few years, the not-for-profit ECRI Institute, a federally certified patient-safety organization, has been warning hospitals about the errors that copy-and-paste can introduce to electronic health records. Staff use it to move data or summaries between records or between different parts of a record. Errors can occur when an employee copies the wrong text, cuts off text they had intended to copy or copies text into the wrong field. That can lead to missed drug allergies, incorrect discharge instructions or even flawed lab results, just to name a few worst-case scenarios.

Ideally, lab results or imaging studies from third parties or other units of the hospital would flow directly into the EHR through interfaces with other sources with no need to copy-and-paste, but that's not always the case in hospitals that have legacy software systems or poor interoperability.

Between 2013 and 2015, the latest data available, ECRI's database received only 12 reports of copy-and-paste-related errors, but researchers believe that number is highly underreported because the mistakes are obvious to well-trained staff and are quickly corrected, or because they're reported to other departments instead of the hospital's safety staff. Individuals are also unlikely to report their own mistakes, said Lorraine Possanza, a program director at ECRI.

ECRI, along with researchers at the National Institute of Standards and Technology, or NIST, aren't asking providers to stop using copy-and-paste, but rather to be smarter about it. Last year, ECRI released recommendations on how providers and EHR vendors should guard against these errors.

First, providers and vendors​ should make it easy for users to identify content that was copy-and-pasted. So vendors or hospital IT professionals should look into creating identifiers for copy-and-pasted content, such as the ability for copy-and-pasted text to change color when it's hovered over, a separate pane for copy-and-pasted text or different formatting for that text, Possanza said. Any function like this should be automated.

Mechanisms created by a hospital or vendor to identify copy-and-pasted content should also identify the content's source, along with the context, author, time and date of that document, according to ECRI. In their January analysis of ECRI's recommendations, NIST researchers call this information the "chain of custody," and recommend that any such metadata be presented in a way that isn't overwhelming to users. Crowding of data could lead to errors, said Lana Lowry, a project lead at NIST and a co-author of the analysis.

There's an even more important reason why those errors could occur. "The reason people copy and paste is because it's simplifying their task," Lowry said. "But the reason why they're looking for simplification is because they're overwhelmed," so solutions shouldn't overwhelm them further, she said.

Epic Systems Corp.'s EHR system warns providers who use copy and paste. It also identifies the patient record where the copied text came from. Most Epic users aren't highlighting text and copying it like the average computer user. Rather, they often use built-in "copy" buttons that allow users to copy a specific part of a record such as the physical exam or medical history. That can guard users who might fail to highlight the entire note they're trying to copy. If a user copies discrete data such as vital signs from an earlier record, Epic's system will also update that data.

Providers should train staff to use these functions to their fullest capability. EHR vendors should warn providers against using copy-and-paste in certain areas because of the serious risks that come with an error, Lowry said.

Providers and vendors should regularly monitor and assess providers' copy-and-paste habits, according to ECRI. Epic provides that data in hopes of one day helping providers understand how often they should be using the functionality. It's important to retain the ability to at least copy things that don't often change from visit to visit, said Dr. Sam Butler, Epic's chief medical officer.

"There is a sweet spot for how much we should copy and how much we shouldn't copy, and I don't think we know that yet," Butler said. "There are people who say you shouldn't be able to copy anything forward—that would be an awful burden."