Copying and pasting of EHR data may insert problems

When reviewing a patient’s history, a physician might be faced with pages upon pages of previously added clinical notes. By some estimates, the typical patient note is 4,000 characters—roughly 1.5 pages—and those add up over time.

Memories of those overstuffed medical records weighed on Rep. Dr. Phil Roe (R-Tenn.) during a congressional hearing this past summer, while questioning leaders from the Defense and Veterans Affairs departments on whether they were adequately engaging physicians in the implementation of their co-developed electronic health record system.

During the hearing, Roe recalled frustrations he ran into while practicing as a doctor and working with exceedingly lengthy patient notes in the EHR.

Though there are many reasons for long-winded documentation, Roe pointed a finger at two seemingly small computer commands that he felt had complicated his time as a doctor: Control-C and Control-V.

Copy-and-paste, two simple computer shortcuts, might not seem like a major concern for healthcare organizations, but in practice they can lead to loads of employee frustration and possible clinical errors.

“I saw it; it’s an experience I had,” Roe said during an interview with Modern Healthcare. Overuse of copy-and-paste would lead to lengthy patient records—sometimes leaving him to dig through 10 or so pages of information to find useful patient data. Other times, it meant getting patient notes from a referring physician, only to realize an error had been repeated throughout the record for months, if not years.

With copy-and-paste, “if you don’t read that whole thing, that misinformation stays in there,” he said. That can be true for something as simple as mixing up whether a patient is referencing a condition on their left or right side. If that information’s added to the record incorrectly, it could be copied-and-pasted for “two or three or four visits, just compounding an error that’s already in there,” Roe said.

Copying-and-pasting information like medical histories and discharge summaries from previous patient notes is just one of the many so-called “workarounds” clinicians have employed to save time while documenting in the EHR.

And while these shortcuts can help make an imperfect process often considered a core driver of provider burnout—EHR documentation—more efficient for an individual physician, it creates long-winded and imprecise notes. Voluminous notes make it difficult for future members of the care team to parse through details of a patient’s medical care, not to mention creating complications for coding and reimbursement.

“I would get a stack of paper this much,” Roe said at the June hearing, holding his fingers an inch or so apart. “And I’m thinking, ‘Somewhere in this pile … there’s some information I might be able to use—if I can find it.’ ”

The rationales often cited for why physicians employ EHR workarounds include efficiency and saving time, despite the challenges created down the line.

“They’re trying to find a way to save time, so they can take care of their patients,” as well as cut down on the time they’re documenting after hours, said Tammy Combs, a director of health information management practice excellence at the American Health Information Management Association.

Primary-care physicians now spend more time in the EHR than on face-to-face time with patients, with most physicians completing EHR documentation after hours, according to a study published in the journal Family Medicine last year. Copying-and-pasting notes from a previous visit, rather than writing original information, can help to cut down on that time.

It’s not an infrequent occurrence. Only 18% of text in inpatient progress notes are original entries by clinicians, according to a 2017 study conducted at UCSF Medical Center and published in the journal JAMA Internal Medicine. The remaining 82% of text tended to be copied or imported.

And copy-and-paste isn’t the only so-called “workaround” clinicians use to ease EHR documentation. Overuse of functions like pre-made templates or relying on “favorites” lists can also offer a trade-off between specificity and efficiency for providers, Combs said. “These tools can be beneficial, if they’re updated to ensure the documentation is accurate.”

But if that information isn’t reviewed for accuracy, problems can arise.

Importing content to the patient record, without adding details or checking for accuracy, creates the possibility of repeating outdated information, such as a diagnosis for a condition that’s been resolved, said Dr. Mark Jarrett, chief quality officer at Northwell Health in New York, who co-led a work group focused on EHRs with the Institute for Healthcare Improvement’s Leadership Alliance in 2015-16. And as Roe mentioned at the House hearing this summer, copy-and-paste can enshrine inaccurate information in the record, if a physician accidentally repeats incorrect data that’s later repeated.

“Now, it becomes—in perpetuity—part of the medical record,” Jarrett said.

Even if the data is accurate and up-to-date, there are issues  with the sheer volume of information that’s now held in each patient note. Much of that information is likely redundant.

“If you’re copying-and-pasting materials, which technology allows us to do, you’re able to capture more complete information—but you’re also making those notes excessively long,” said Lorraine Possanza, program director of the ECRI Institute’s Partnership for Health IT Patient Safety. That can make it difficult for other members of the care team to decipher what’s most important down the line.

Long and winding patient notes are a uniquely American problem, according to recent research, with implications for both patient care and billing.

Physicians in the U.S. write patient notes that are nearly four times longer, on average, than those in other countries, according to an analysis published in the journal Annals of Internal Medicine last year. That’s in part because patient notes in the U.S. are expected to contain documentation related to compliance and reimbursement, in addition to clinical information.

But some of that so-called “note bloat” is driven not only by policies that tie reimbursement to documentation but also by confusion over those policies, said Dr. Christopher Longhurst, chief information officer at UC San Diego Health and co-author on the article. Physicians, who are encouraged to be risk-averse, have “often been taught to do more than is necessary,” Longhurst said.

That can lead physicians to be overzealous in pulling in information from previous notes if they’re unsure what data will be pertinent for reimbursement.

“There’s a reality that things have to be in the note for billing purposes,” Longhurst said. “And then there’s a gap where some institutions think there needs to be more than is actually required.”

But functions that drive note bloat, like copy-and-paste or plugging information into pre-made templates, can actually hurt—not help—when it comes to reimbursement.

Templates that lack specificity might miss relevant clinical data, according to a set of best practice guidelines from AHIMA—and if the documentation doesn’t match a claim that’s later submitted, a payer might deny reimbursement for that care. There’s also the issue of pulling too much information from a previous note, as copying-and-pasting without proper review might lead a physician to unintentionally document services that were completed during an earlier visit, leading to questions of misrepresentation or even fraud.

And having many notes that look similar, in general, can also raise red flags for payers. If a hospital is ensnared in a billing dispute, one of the first steps might involve reviewing relevant patient notes to ensure they support what’s coded. “If all your charts look the same, that smells bad,” said Andrew Selesnick, an attorney with law firm Buchalter’s healthcare practice group.

In many EHRs, there’s a way for health systems to disable the copy-and-paste function. But that’s not the answer, said UC San Diego Health’s Longhurst. “There’s no question that copy-and-paste can be misused or overused, but it’s also a helpful function for reducing burden when it’s appropriately used,” Longhurst said. “There’s a place for it, and turning it off completely is not helpful.”

Setting policies to delineate that line—where it’s OK to copy-and-paste, and where it’s not—and figuring out how to monitor physician adherence is imperative, according to AHIMA’s Combs.

“Have detailed policies and procedures,” Combs said. “What are the scenarios in which it would be OK to copy-and-paste? What are the expectations for the provider?”

Two core components of the data-replication policy at UW Health in Wisconsin are requiring physicians to review any copied information for accuracy and prohibiting copying information from one patient’s record into a separate patient’s record, said Dr. Shannon M. Dean, chief medical information officer and associate professor of pediatrics at UW Health.

“Copy-and-paste is reasonable, as long as the provider is adequately editing the information to ensure it’s still up-to-date information and relevant for that day’s care,” she said.

Ensuring that those reading a patient note understand the data’s provenance, or where the information originated, is also a key part of keeping tabs on inappropriate use of copy-and-paste.

In a set of recommendations for safe use of copy-and-paste, ECRI’s Partnership for Health IT Patient Safety suggested making it easier to identify what information had been replicated and providing attributions for where the content originated. The National Institute of Standards and Technology has also released recommendations emphasizing the importance of knowing the source of copied content.

That’s something UC San Diego Health has tackled by using functions in the EHR system that allow readers of a note to see what information was manually entered by the physician writing the note, and what was pulled from another system. For content that’s been copied or imported from elsewhere, it also displays the source where the information was pulled from.

“That’s a very useful feature in terms of understanding what’s the new information in the note,” Longhurst said.

Beyond ensuring physicians can review the provenance of information in individual patient notes, hospital leadership should establish a way to monitor how copy-and-paste is being used across the organization. Some EHRs offer a way to automatically measure the amount of information being copied across units, so leadership can conduct audits and look for outliers.

Health systems should be conducting annual audits of their documentation, coding and billing practices as part of their compliance programs, said Damaris Medina, another attorney with Buchalter’s healthcare practice group and co-chair of the law firm’s life sciences practice.

But it’s not as easy as setting policies. By definition, workarounds are a way to get around a seemingly flawed system—and for physicians, that’s the EHR.

Physicians use workarounds like copy-and-paste to make their day more efficient, said Dr. Melinda Ashton, chief quality officer of Hawaii Pacific Health. “You can discourage all you like,” she said. “If the tools don’t make it easy to do the right thing the right way, workarounds are going to occur.”

So to address EHR workarounds, she said what health systems really need to address is documentation burden.

At a national level, that’s part of what the CMS is working on with its Patients over Paperwork initiative, an effort to reduce administrative loads that regulations have placed on clinicians, as well as the mission behind a strategy to reduce EHR administrative burdens that the CMS and the Office of the National Coordinator for Health Information Technology proposed last year. But as physicians are waiting to see relief from these efforts, health systems are standing up their own programs to tackle documentation burden.

Hawaii Pacific Health in 2017 launched a program called “Getting Rid of Stupid Stuff”—an effort to identify and eliminate documentation requirements that add unnecessary work. As part of the program, employees are encouraged to report so-called “stupid stuff” they think leadership should address, Ashton said.

One of the program’s biggest successes to date has been eliminating outdated or repetitive decision-support alerts. By identifying the most frequently deployed alerts, and asking clinicians whether they were useful, Hawaii Pacific Health has been able to remove “thousands” of pop-up alerts that “weren’t achieving what they were intended to achieve,” said Dr. James Lin, medical informatics director at the system.

At UC San Diego Health, the health system has set up multidisciplinary teams of IT and operations staff that rotate through different clinical services to study and redesign workflows in a way that makes them more efficient for providers. That might include offering EHR usability tips, software shortcuts or clarifying what information is—and is not—required to be documented in a patient note.

UC San Diego Health also offers one-on-one documentation training and walk-up technology support stations for physicians, but has found retooling workflows by specialty as particularly helpful.

“There’s only so much that you can do from an individual physician’s perspective,” Longhurst said. “At the end of the day, team-based care is the key to mitigating physician burnout.”