The Electronic Health Record Risk

The copy and pasting feature on most computer applications can be a serious risk in regards to the electronic health record. While we in our personal lives find this feature to be something that makes our lives easier, the act of copying or cloning text from locations in a health record raises a whole other sort of problem.

According to Bowman (2013), copying and pasting an electronic health record pose risks to documentation integrity resulting from incorrect use of the copy and pasting functionality. This can raise issues on many levels, but most importantly the probability of errors within the record. As nurses some of the problems that can arise include copying old and outdated information, repeating information that was already wrong to begin with, the inability to indentify the true author, the inability to accurately identify time, and the repetition of information that is unnecessary.

I have witnessed nurses use the copy and paste feature in the electronic health records in my practice on many occasions. In most cases, it is used as a way to save time. This can be understood as nurses want to spend less time documenting and more time with their patients. In most cases, the nurse still reviews the information and makes changes to include current information but this is not always the case. For example, Bowman (2013) describes a case study published in the Agency for Healthcare Research and Quality where copied and pasted text led to a failure to administer medication, resulting in the patient being readmitted for a serious medical condition. In another reported case, copying and pasting the same note for several days in a row nearly resulted in a patient’s treatment being changed because the note had not been updated to reflect the true state of the patient’s condition. In both of these cases there were serious consequences related to the copying and pasting of information.

The reasons nurses use the copy and paste feature is understandable. Documentation takes an enormous amount of time and in many cases the information you are charting seems redundant. For example, if I am charting on a patient every two hours and nothing changes related to a wound, it seems understandable that copy and pasting would be quicker than continually saying the same thing over and over. However, then redundancy becomes apparent. According to Bowman (2013), the ease with which documentation can be copied and pasted has resulted in clinician complaints that electronic health records are cluttered with unnecessary information making it difficult to read the record and to locate important details. You can see how this can have implications for clinical decision-making as well as medical malpractice litigation.

Recent studies on the prevalence of copying and pasting in the electronic health record indicate that the practice is very common among health care workers. If this is being seen as such an issue is regards to integrity and safety, it seems to make sense that the electronic health record would eliminate the copy and paste feature in order to prevent health care workers from using it. While this may not make life easier for those of us having to document, there are perhaps ways we can streamline the documentation in order to make it easier but prevent actual copying. For example, it would be nice when doing checks every two hours to be able to easily say there has been no change since the previous check without having to repeat everything that was described two hours ago. The electronic health record does include repetitious information that perhaps can be streamlines so health care workers are not so tempted to copy and paste to save time.

In my institution, it would be very interesting to do a survey of health care workers to find out how many are actually using the copy and pasting feature. The survey could also identify anonymously if those that use are checking their documentation carefully to ensure its accuracy. In addition, if there has ever been a time where documentation or treatment were compromised or even if it could have been compromised related to this practice. This could be a very eye opening study to determine the prevalence, risk and outcomes related to this documentation feature.

                                                            References

Bowman, S. (2013). Impact of electronic health record systems on information integrity:  Quality and safety implications, 1-19.