Copying and pasting of EHR data may insert problems Jessica Kim Cohen Modern Healthcare Illustration When reviewing a patient's history, a physician might be faced with pages upon pages of. "Cloned" documentation is often done when trying to save time and/or when the patient has not been fully assessed, leading to errors continuously being forwarded in a patient's record. 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 patients record into a separate patients record, said Dr. Shannon M. Dean, chief medical information officer and associate professor of pediatrics at UW Health. Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions. Documentation review may need to be incorporated into peer review processes in order to heighten the importance it plays in communication and patient safety. 0 Let us take the hard work out of your job search with the new Nurse.com Jobs. Us, In Conversation With Robert Hirschtick, MD. Policies, HHS Digital Utilizing EHR alerts to deliver recommendations to physicians specific to a patient's condition and level of risk can help to facilitate more accurate care delivery for improved patient health . In Conversation With John Halamka, MD, MS. Thoughtless design of the electronic health record drives overuse, but purposeful design can nudge improved patient care. AHRQ Health Information Technology Division's 2017 Annual Report. And thats what makes documenting difficult.. I can understand copying and pasting vital signs as noted by the ICU nurse. Shannon M. Dean, MD Chief Medical Information OfficerUW Health Associate Professor of Pediatrics University of Wisconsin School of Medicine and Public Health Department of Pediatrics Division of Hospital Medicine Madison, WI, 1. Only 18% of text was manually entered. ph)t?h9@+h$U(h If all your charts look the same, that smells bad, said Andrew Selesnick, an attorney with law firm Buchalters healthcare practice group. Please Then, they had to track down all the locations they sent that information. These potential issues Looks like youre not logged in! Using the copy and paste function with electronic medical records is a questionable ethical and legal manner in which to document patient care. Research published in JAMA Internal Medicine[ 1] this past month confirmed what I've been seeing over the past decade or so, in which electronic medical records (EMRs . 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. Sign up for enewsletters and alerts to receive breaking news and in-depth coverage of healthcare events and trends, as they happen, right to your inbox. AHIMA to ONC: Better clinical documentation needed to ensure EHRs' efficacy, EHR Association urges CMS to extend comment period for prior authorization process, Cleveland Clinic's virtual second opinions shown to impact patient care, American Hospital Association voices support for telehealth expansion bill. It seems clear that we need more research examining the potential link between copy and paste and patient safety outcomes. MIPS: Merit-Based Incentive Payment System, Epic Tip of the Week: How to Copy a Previous Assessment, https://www.mbahealthgroup.com/wp-content/uploads/2015/07/mba-healthgroup-logo21.png, Allscripts v11 Note Forms: To Customize or Not to Customize, FAQs: Attesting for Meaningful Use Stage 1 & Stage 2, Transitioning from in-house billing to outsourced billing, 8 Benefits of Outsourcing Medical Billing, Start a Medical Practice without Making these 5 Mistakes, 9 Steps to Successfully Starting a Practice. Find evidence-based sources on preventing infections in clinical settings. No need to retype patient history. Note that even if you have an account, you can still choose to submit a case as a guest. (6) The second study, by Turchin and colleagues, found that copied and pasted lifestyle counseling in patients with diabetes was less effective in controlling glucose than "net new" counseling statements. In our era of electronic medical record (EMR) adoption, the practice is highly prevalent, with 90% of physicians reporting copy-and-paste use. An electronic health recordbased real-time analytics program for patient safety surveillance and improvement. Much of that information is likely redundant. Several questions should be asked when developing policies and procedures: In addition, the ECRI Institute held a workshop in 2016 that identified 4 safe practice recommendations for using copy/paste features: Not all information needs to be copied from previous notes and other documents, and knowing what to edit can help prevent note bloat, when documents such as progress reports become overwhelming from copying too much content, Warner says. Generally, the function can be used for copying patient regular medications, long standing allergies, demographics, problem list and labs and treatments if they're ongoing. Several professional organizations have published consensus statements and toolkits, which can be used for the basis of education and mentoring around this issue. It goes through other systems. the <> What are the expectations for the provider?. @p2;0W ,|$6%%L,| S]4. Program name: Epic (Productivity) Epic is a cloud-based patient and healthcare management software used in hospitals. AHRQ WebM&M [serial online]. PSHwzSnQ! |*;+a6S%I&:6}iB2L Unfortunately, Hirschtick's call to action at the time, along with those of others over the years (2,3), has not resulted in the kind of improvements in provider documentation that might prevent harm from copying and pasting. Remember, we are the number one most trusted profession. But is it? Off the recordavoiding the pitfalls of going electronic. For example, Epic's EHR can now identify the source of every character within a note, whether it is newly typed, imported from another source, or copied and pasted. Teach Learn Med. 239 0 obj <>/Filter/FlateDecode/ID[<9F333FF88DAB11C3D89667E7235FAE40><9EEFC63CBF4DE84B86038F4470988560>]/Index[177 77]/Info 176 0 R/Length 215/Prev 451151/Root 178 0 R/Size 254/Type/XRef/W[1 3 1]>>stream Types and origins of diagnostic errors in primary care settings. [go to PubMed], 15. Sebelius and Holder pointed to reports of hospitals using EHRs to "upcode" patients' medical conditions, abuses which have been estimated to cost nearly $11 billion, according to a year-old report from the Center for Public Integrity. Copy/paste documentation of lifestyle counseling and glycemic control in patients with diabetes: true to form? 2. can view the information on the summary or reference panel in the Meditech EHR and use the scratchpad feature to copy and paste any of it into . Remember that as a licensed nurse, you are responsible for the care you provide and for the accurate and complete documentation of that care, regardless of whether it is in a handwritten format or in the EMR. endobj As a Professional nurse with many, many years experience under my belt, working very long hours for relatively poor pay and the constant necessity for continuous training in order to maintain my Professional registration with my Professional regulatory body! If this is the case, we most certainly need to provide oversight in the use of copy and paste and provide critical feedback to our trainees and to our peers when we see it being used inappropriately. MH magazine offers content that sheds light on healthcare leaders complex choices and touch pointsfrom strategy, governance, leadership development and finance to operations, clinical care, and marketing. This will prompt you to enter the staff password, which is "staff", unless you changed it. endobj Wow! %PDF-1.5 % Make copy-and-paste material easily identifiable. = 2011;171:1393-1394. Ah`JD!6) J$;F'"2Pp (YF EMRs are used in clinician offices, clinics, and hospitals. Safe Practices for Copy and Paste in the EHR: Systematic Review, Recommendations, and Novel Model for Health IT Collaboration, American Health Information Management Association: , Appropriate Use of the Copy and Paste Functionality in Electronic Health Records, . AHIMA Position Statement (accessed February 10, 2015), Health IT Safe Practices: Toolkit for the Safe Use of Copy and Paste. Stewart E, Kahn D, Lee E, et al. 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. (10-12) In the technology realm, a few vendors have developed tools for easily identifying copied and pasted material and the provenance of the copied content. Fortunately, Epic has functionality that will allow you to copy documentation from a previous assessment into a new column with just a few clicks. Documents i have read makes me believe copy past used this particular way is not fraud. The Electronic Medical Record: Auditing the Copy and Paste Function Presented by: Kathleen Enniss CPC CHC Compliance Analyst UW Medicine Compliance University of Washington kenniss@uw.edu 2 The EMR: Positive Impacts Saves charting time Templates Copy and paste functions "Make it my note" Allows real time access to previous notes from other "Why is copy and paste a bad idea? At work, I have started to see copy and paste documentation in the home health record for patient instruction. Assessment of the use of patient vital sign data for preventing misidentification and medical errors. It's so easy to dojust use the "copy and paste" feature in an electronic health record (EHR), and all the prior information about a patient appears in the document. Appl Clin Inform. With so many practitioners using the copy and paste feature, more awareness about potential issues, as well as collaborative solutions from all involved, is needed, Warner says. Theyre trying to find a way to save time, so they can take care of their patients, as well as cut down on the time theyre documenting after hours, said Tammy Combs, a director of health information management practice excellence at the American Health Information Management Association. Lastly, the potential impact of payment reform, with its focus on quality and outcomes, cannot be underestimated, as it may allow the note to be used more for clinical communication rather than for billing or coding, thereby freeing the provider from the perceived need to include extraneous information. 8 0 obj We now need organizations to start using these toolkits and auditing features to help elucidate how best to educate, implement change, and incorporate supportive technologies. 2. Winn W, Shakir I, Israel H, Cannada L. The role of copy and paste function in orthopedic trauma progress notes. 2015;10:525-529. I've been working in healthcare for The current state of the EMR includes cloning, canned notes, and copy/paste capabilities. It's pretty easy to see how it's easy to miss things when you start copying and pasting into an EMR. [go to PubMed], 12. I have been researching this for a couple of weeks. The use of the copy-and-paste function (CPF) in health care providers 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. In Defense of Copy-ForwardBy Lyle Berkowitz, MD. The use of copy and paste in medical documentation raises many concerns. [go to PubMed], 17. Singh and colleagues identified 190 diagnostic errors. Here are the steps to copy favorite orders. This is a permanent role by way of contract-to-hire with an . endobj Although these options can be real time-savers, you should still be very careful before filing any data. Dean SM, Eickhoff JC, Bakel LA. endobj A spokesperson for Epic, the largest U.S. EHR . [Available at], 2. [go to PubMed], 7. [go to PubMed], 3. Shoolin J, Ozeran L, Hamman C, Bria W II. This includes entry while editing a transcribed document, or direct copy/paste into Epic. [go to PubMed], 4. 2 0 obj Using the WHO International Classification of patient safety framework to identify incident characteristics and contributing factors for medical or surgical complication deaths. For example, we should explore natural language processing and its potential role in helping providers review their documentation for accuracy. Appropriate Use of the Copy and Paste Functionality in Electronic Health Records. Epic has a variety of tools that can make writing patient notes faster and easier: SmartPhrases Also known as "dot phrases," SmartPhrases allow commonly used chunks of text to easily be inserted into patient notes or discharge instructions by typing a period (the dot) followed by a short user generated phrase. x\}nGLp-@Ouh/^+>29#X"A"dERy9Qa]?Gg~vx See how our expertise and rigorous standards can help organizations like yours. However, the problems might not be as obvious. But even as the research base expands, we already have published guidelines and toolkits for the safe use of copying and pasting. More information >> Copy. (4) The fact that we continue to use a tool that we acknowledge as unsafe without taking real action to improve its use is a blot on our profession. To copy a flowsheet column, click on the white triangle that appears when you hover your cursor over the time at the top of the column. You can discourage all you like, she said. We should research the impact of voice recognition software on provider efficiency and how this may influence providers' sense that they "need" to use copy and paste. Theres only so much that you can do from an individual physicians perspective, Longhurst said. Applied EPIC Hot Keys and Shortcuts Charles L. Crane Agency Company, Inc. In essence, practitioners should be storytellers. Improper documentation and not performing assessments can lead to improper care which can lead to lawsuits and losing your nursing license. Either a person I a professional or they are not. 15 0 obj Overuse or incorrect use ofthe copy and paste feature in EHRs can bedangerousand can havelegal ramifications, including insurance fraud or loss of money from billing errors due to convoluted information for coding, Warner says. But for responsible, ethical and legal patient care documentation, the function should be used judiciously and in accordance with your healthcare entitys policy concerning its use. But as physicians are waiting to see relief from these efforts, health systems are standing up their own programs to tackle documentation burden. below. The remaining 82% of text tended to be copied or imported. 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 werent achieving what they were intended to achieve, said Dr. James Lin, medical informatics director at the system. The PCP copied and pasted the Assessment and Plan (A/P) section of the patients record for 12 office visits during the next two years, updating the A/P or reviewing medical entries from the ED or other department. 2013;173:418-425. JAMA Intern Med. If the cuff is on the left upper arm, it usually stays there. But thats not the answer, said UC San Diego Healths Longhurst. Administrators have the ability to decide what can and cannot be copied forward. 177 0 obj <> endobj Singh H, Giardina TD, Meyer AN, Forjuoh SN, Reis MD, Thomas EJ. Plymouth Meeting, PA: ECRI; February 2016. If a hospital is ensnared in a billing dispute, one of the first steps might involve reviewing relevant patient notes to ensure they support whats coded. 01 Mar 2023 16:18:26 Master Files - the tables that store Records and Items . Perhaps we are complacent about copy and paste because we remain unconvinced that there is a correlation between its use and patient safety. Workarounds to intended use of health information technology: a narrative review of the human factors engineering literature. Find out about the current National Patient Safety Goals (NPSGs) for specific programs. And Im thinking, Somewhere in this pile theres some information I might be able to useif I can find it.. {}'M'_KeV|qp?7nM08WCBoW &wx9}u=xiBX:o|hpQusMwirX\r[Jwxv)/|W]rU8iI?=~OBi.w.IHp2;eTKp|x6N5$X',CSNP'-Z K>#8pB]sr)#l)lJ%OW.HHp2;(W"'yKj*}xBBR(Z! G*yKNPg6VXxIAC+8ai{vzOn>bJ5bO[*;W mI,{zO.HHp2;0W"'mIl=K\(kH It usually stays there with the new Nurse.com Jobs the cuff is on the left arm. 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