Providers must consider patient safety concerns associated with the overuse of copy-and-paste functions within EHRs, Shannon M. Dean, MD, chief medical information officer of Madison-based UW Health, wrote in an op-ed for the HHS Agency for Healthcare Research and Quality's Patient Safety Network.
A recent study of 23,630 electronic inpatient progress notes published in the journal JAMA Internal Medicine found only 18 percent of notes constituted original entries by clinicians. Thirty-six percent of notes were imported from another source, while 46 percent were copied-and-pasted from a previous note.
The use of copy-and-paste functions in clinical notes raises a few concerns, according to Dr. Dean. For example, it may contribute to a physician creating a "rambling" note about a patient's history instead of focusing on key aspects of his or her current health status.
As an example, Dr. Dean cited a 2013 study in JAMA Internal Medicine that determined 35 percent of 190 diagnostic errors in primary care clinics could be attributed to mistakes made while copy-and-pasting within EHRs.
"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," she wrote in her op-ed.
To remedy the issue, Dr. Dean suggested healthcare researchers investigate the potential link between copying-and-pasting information and patient safety more rigorously. She also recommended hospitals implement review processes to provide feedback to clinicians who heavily rely on copy-and-paste functions.
As technology evolves, Dr. Dean also noted innovations in natural language processing and voice recognition software may provide other avenues to streamline clinical documentation for providers.
"Ultimately, physicians need to reestablish ownership of the accuracy of clinical documentation," she wrote. "We must stop blaming the EHR for our carelessness and start educating ourselves about how to use documentation efficiency tools, including copy and paste, more responsibly."
To access Dr. Dean's op-ed, click here.