June 2017

Editor's Note: Docs Can't Help Themselves
By Lee DeOrio
For The Record
Vol. 29 No. 6 P. 3

Addiction is a terrible thing. Addicts may be told countless times how their behavior, if maintained, will inevitably lead to harm, both to themselves and others. Still, the advice falls on deaf ears.

In the HIM world, there's an addictive behavior that continues unabated. Its consequences are often difficult to quantify, but there's no question they are affecting patient care at its core. Frequent warnings have been issued, including alarm bells from the National Institute of Standards and Technology and AHIMA, to no avail.

The latest news on the use of copy and paste is perhaps the most sobering yet. Last month, researchers from the University of California San Francisco Medical Center announced the results of a comprehensive study that measured copy-and-paste practices over an eight-month period, covering more than 23,000 progress notes from 460 clinicians. The researchers used a new tool that "distinguishes manual, imported, and copied text in hospital progress notes with character-by-character granularity to describe documentation practices by medical students, residents, and direct care hospitalists."

The results should strike fear into clinical documentation improvement specialists, compliance officers, HIM directors, and patients. Published in JAMA Internal Medicine, the study found that 46% of notes were copied and 36% were imported. Only 18% of the text was entered manually.

"It is disheartening to see that copy and paste is still such a pervasive problem despite cloning having been a specific target of the Office of Inspector General," says Erica E. Remer, MD, FACEP, CCDS, founder and president of Erica Remer, MD, Inc.

There's little argument that physicians consider documentation akin to spending a warm sunny day in the dentist's chair. Any way to speed the process is met with open arms, consequences be damned. Remer says the direst outcome of copy and paste is "the ceding of careful reflection about the current status of the patient to the convenience of getting your notes completed expeditiously."

Possible solutions run the gamut from disabling the copy-and-paste function to denying payment when the tool is used repeatedly. "I think the solution is multifactorial," Remer says. "Education is a good start, but EHR technology must assist. There should be a mechanism for identifying nonoriginal text (ie, different font), and the provenance must be readily available (eg, source, author, date/time). The creation of novel, up-to-date documentation should be at least as easy as copy and pasting."

Has it reached the point where physicians need to be incentivized to not use copy and paste? Let's hope not.

edit@gvpub.com