The Dangers of Copy and Paste in the EHR

Bob Swerlick rswerli at GMAIL.COM
Wed Oct 26 15:52:18 UTC 2016


It is unfortunate that EHR's as currently configured are awful information
communication tools. They were sold as billing justification tools and the
way this was accomplished is by bloating the note with information to
facilitate the work of billing coders. People respond to incentives and the
incentives currently are to make notes extensive because the more stuff you
load in, the more likely you will hit the bullet requirements for to bill
at level 4 or 5 visits. The coding system divorces activity required for
adding value to the practice from the what is required to add value to
patients.

One barrier to improving them is a lack of consensus as to what information
do clinicians need to be in front of them to do their jobs. Ask 10
clinicians what they need to make good decisions and you will get 10
different answers. Unlike the uncertainty associated with defining what
information is really needed to make good decisions, the information needed
to enhance billing is reasonably well defined. Thus, it is no surprise that
the notes generated reflect the billing requirements. There is consensus on
what these are and there are financial incentives to include them.

My own approach to note bloat is to put my assessment and plan at the top
of my notes. The assessment generally summarizes key recent history, what I
think is going on (DDx if the visit has a diagnostic element) and my plan.
Everything else is just data upon which I have based the assessment and
plan. Some of the data is new and some of the data is old.

To single out cut and paste as a culprit in creating awful notes is
reasonable but it is by no means the culprit or even the major culprit. To
create a more functional EHR we will need to rethink how and when we
document and more importantly, rethink how we get paid. Until compensation
is more linked to creating of value for patients and less linked to buffing
the chart, expect more of the same.

On Wed, Oct 26, 2016 at 10:14 AM, Hoffer, Edward P.,M.D. <
EHOFFER at mgh.harvard.edu> wrote:

> Probably the greatest danger from cut-and-paste is loading the note with
> so much extraneous material (full text of pathology and imaging notes,
> discharge summaries, etc), that the reader of the note has no idea what
> transpired at the actual visit!  One of our local specialists produces
> notes that can run 8-10 pages, and I then have to telephone him to find out
> what happened at the patient visit.  Some EMR users seem to think that a
> very long note justifies higher visit code.
>
> Ed
>
> Edward P Hoffer MD, FACC, FACP, FACMI
>
>
>
> *From:* rkoppel [mailto:rkoppel at SAS.UPENN.EDU]
> *Sent:* Saturday, October 22, 2016 4:58 PM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] The Dangers of Copy and Paste in the EHR
>
>
>
> You may be interested in this piece on cut and paste from Chest.
>
>
>
> Ross Koppel, PhD, FACMI
>
> UNIVERSITY OF PENNSYLVANIA
>
> Sociology Dept;  LDI Senior Fellow, Wharton; &
>
> Affil Fac. Sch. of Medicine.
>
> Chair, AMIA Clinical Information Systems Working Group.
>
> Ph: 215 576 8221; Cell 215 518 0134
>
>
>
>
> ------------------------------
>
> *From:* Elias Peter <pheski69 at GMAIL.COM>
> *Sent:* Saturday, October 22, 2016 8:12 AM
> *To:* IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
> *Subject:* Re: [IMPROVEDX] The Dangers of Copy and Paste in the EHR
>
>
>
> I am curious about their precise definition of copy/paste, and how they
> identified it operationally. Specifically, did it include things like:
>
>
>
>    - A clinical list (problems, medications, allergies) that
>    automatically populates a note without the user actively copying/pasting.
>    - A social history that carries forward without a specific copy/paste
>    action by a clinician.
>    - An immunization record that carries forward without a specific
>    copy/paste action by a clinician.
>    - Problem-specific history or findings that auto populate a note based
>    on internal EHR logic, often seen with chronic problems documented with
>    templates: chronic pain, fall risk, services due, hypertension, CHF.
>
>
>
> These have the same implications as copy/paste by a clinician, but may not
> have been captured. They may also be very hard for a clinician to identify
> or remove from a note.
>
>
>
> Peter
>
>
>
> On 2016.10.22, at 1:16 AM, HM Epstein <hmepstein at GMAIL.COM> wrote:
>
>
>
>  I was surprised by this report from ECRI. They did a retrospective look
> at EHRs and found only 7.4% used cut-and-paste. However, of that small
> sample, 36% of the cut-and-paste entries contributed to Dx error.
>
>
>
> Based on all of the complaints I've read about cut-and-paste use in EHRs,
> I truly expected to see that the incidence was much higher. Has anyone seen
> other studies to compare to this? Does it accurately reflect your
> expectations from your own observations in your place of work?
>
>
>
> Thank you.
>
>
>
> Best,
>
> Helene
>
>
>
> http://www.diagnosticimaging.com/ehr/dangers-copy-and-paste-ehr
>
>
> The Dangers of Copy and Paste in the EHR
>
> October 21, 2016
>
> *By Erica Sprey <http://www.diagnosticimaging.com/authors/erica-sprey>*
>
> By nature of design, EHR systems encourage physician users to copy old
> patient data, like medication lists and chronic conditions, and copy and
> paste the information into the current note. In doing so there are benefits
> and risks for both physicians and patients, according to Lorraine Possanza,
> DPM, JD, and Robert Giannini, NHA, of the nonprofit ECRI Institute
> <https://www.ecri.org/Pages/default.aspx>. Possanza and Giannini were
> co-presenters at the American Health Information Management Association's (
> AHIMA <http://www.ahima.org/>) annual conference in Baltimore, Md., held
> on Oct. 17, speaking on "Safe Practices for Copy and Paste."
>
> The ECRI Institute's mission is to provide physicians and other health
> professionals evidence-based guidelines on the most effective medical
> procedures, devices, and drugs, via scientific research. In order to
> understand the affect that potentially unsafe practices like "copy and
> paste" have on patient safety, ECRI applies a three-prong approach, says
> Possanza. This includes data collection; data analytics; and leveraged
> learning that reaches out to both EHR vendors and medical staff.
>
> While reporting can seem onerous to overworked staff, it is vital to
> understand the extent of the problem. Possanza provided conference
> attendees an example where copy and paste can hinder the physician and her
> staff as she treats a hospitalized patient who suffers from pressure
> ulcers. If the initial assessment is copied and pasted forward in the note
> on subsequent patient visits, the physician does not have a true picture of
> the progression of the ulcers and may not trust the validity of the
> information in the note.
>
> Copy and paste also contributes to "note bloat" says Possanza, making it
> difficult for a physician to pick out pertinent information that is
> swallowed up by redundant information. It is vital that patient information
> is accurate, timely, and easily assessable she says, adding that a dense
> note can contribute to diagnostic error.
>
> The ECRI Institute did a retrospective study on diagnostic error that
> found 7.4 percent of audited charts contained copy and paste information,
> and of that group, 36 percent contributed to diagnostic error. "How does
> copy and paste influence [diagnostic error]? Through note bloat, through
> those internal inconsistencies, through the propagation of errors," says
> Possanza. "If I pasted information and it's incorrect and I repeatedly
> paste that information that is incorrect, I now have errors that are
> propagated."
>
> In order to minimize the chances of error, Possanza says physicians and
> other clinicians must be accurate in their notes, concisely document the
> patient information, attribute where copy and paste material came from, and
> give context where appropriate.
>
> It is essential that physicians and other medical staff feel that they can
> report health information technology (HIT) related-errors in a non-punitive
> environment, so that management can address any systemic problems. And it
> is also equally important that staff are trained on copy and paste best
> practices. To that end, the Partnership for HIT Patient Safety
> <https://www.ecri.org/resource-center/Pages/HITPartnership.aspx> has
> released the first "Health IT Safe Practices: Toolkit for the Safe Use of
> Copy and Paste,"
> <https://www.ecri.org/Resources/HIT/CP_Toolkit/Toolkit_CopyPaste_final.pdf> which
> examines the scope of the problem, defines the various stakeholders and
> provides safe-practice guidelines for providers.
>
> The Partnership has developed four recommendations for providers and their
> staff, says Possanza:
>
> A: Provide a mechanism to make copy and paste material easily identifiable;
>
> B: Ensure that the provenance (and chronology) of copy and paste material
> is readily available;
>
> C: Ensure adequate staff training and education regarding the appropriate
> and safe use of copy and paste; and
>
> D: Ensure that copy and paste practices are regularly monitored, measured,
> and assessed.
>
>
>
>
>
>
>
>
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-- 
Bob Swerlick






Moderator: David Meyers, Board Member, Society to Improve Diagnosis in Medicine

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