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Copy-Paste and the EHR:
Realizing the Benefits While Minimizing the Risk

By Linda McIntyre, RN

In the “olden days” before EHRs, physician notes were expected to flow in a narrative style to tell the “story” of the events leading up to and resulting in a patient’s illness or injury. These events were relayed in chronological sequence with relevant clinical commentary regarding diagnosis, prognosis, and treatment plan. Laboratory and other diagnostic results were appropriately included. These notes were typically dictated, transcribed, and then reviewed by the doctor prior to signature.

With the adoption of the EHR, the ability to create their own notes in real time has been a convenient feature for physicians. One function that is frequently used is copy-paste. This can be a great time-saver since it allows a physician to quickly incorporate lab results, vital signs, and related data into the note.

Unfortunately, there are risks in using this feature too enthusiastically. Copying and pasting data from one note to another can result in documentation that is neither current nor accurate. Whole text from a previous note or history and physical may be pasted into another note, resulting in confusion for another clinician, a coder, or a reviewer as to current status. Also, when a note appears to be a copy of a previous note, either increased effort will be required to read through and discern what new information is present, or the new information may be missed altogether because the reader assumes there is nothing different. And what about copying and pasting information from another clinician’s note? Whose opinion or diagnostic evaluation is this?

A recent Office of the Inspector General (OIG) study investigated safeguards that have been implemented by hospitals in relation to EHRs. The study found that “only about one-quarter of hospitals had policies regarding the use of the copy-paste feature in EHR technology, which, if used improperly, could pose a fraud vulnerability.” In addition, the study found that only 44% of hospital audit logs recorded the method of data entry into the EHR (eg, copy-paste, direct text entry, speech recognition).

So, although copy-paste can enhance the efficiency of data entry, it’s imperative to have policies and standards regarding its use. Otherwise, as the OIG study noted, inaccurate information may enter the patient’s medical record and inappropriate charges may be billed to patients and third-party health care payers. Inappropriate copy-pasting could facilitate attempts to inflate claims and duplicate or create fraudulent claims.

Interestingly, of the hospitals participating in the OIG study, those that did have copy-paste policies seemed to have little control over its use. Most (61%) reported that they left the responsibility of confirming the accuracy of the copied and pasted data with the EHR user, while 21% reported they required EHR users to cite the original source of the copied and pasted data. More than one-half said they did not have the ability to restrict or disable the use of copy-paste within their EHR technology.

One of the outcomes of the OIG study was a recommendation that the Centers for Medicare & Medicaid Services (CMS) develop guidance on use of the copy-paste feature in EHR technology. Until the industry receives this guidance, what can your organization do to address the risk of copy-paste?

Clearly, policies and standards should be developed to address the use of the copy-paste feature. Those noted in the OIG study seem either inadequate (“make sure you check what you copy-pasted”) or too strict and time consuming for the user (“cite the source of the copy-pasted material”). Disabling the copy-paste function altogether does not seem to be the answer either as physicians find it to be an excellent time-saving mechanism.

Education of medical personnel is essential regarding the challenges and risks of using the copy-paste function. Consideration of tracking the method of data entry and development of facility standards should occur in collaboration with those who use the feature regarding what information and from what sources copying and pasting is permitted.

Finally, technology such as natural language processing (NLP) is being used to help identify copy-paste in medical documents. An NLP engine can compare two similarly structured notes and detail their differences. At the same time, the functionality exists to display the detail that has been deleted or changed. For example, a cardiologist completes a progress note. The next day he or she copies and pastes a portion of the previous day’s note into today’s documentation. The second note may look similar to the first except for small changes such as vital signs or updated lab results. Technology helps highlight the differences in the notes as well as any information that may have been deleted.

The copy-paste feature, if employed appropriately, can enhance the efficiency of data entry, but the risks must be addressed by the CMS and hospitals. Since at this point many hospitals cannot customize the copy-paste feature in their EHRs, it’s essential to establish and communicate policies and processes to govern its use. Technology such as NLP can help by automatically identifying copy-paste situations. A proactive approach allows your organization to take advantage of the time-saving benefits of copy-paste while mitigating the risk.

— Linda McIntyre, RN, is consulting services project manager for 3M Health Information Systems.