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Electronic health record copy/paste practice a growing concern

On Behalf of | Feb 12, 2013 | Doctor Errors

The term “sloppy and paste” might intuitively seem most aptly attached to a student’s mediocre writing efforts or media plagiarism.

The description also applies, though, to a practice in the medical field that many commentators are drawing attention to and voicing concerns with, namely, the frequent copying and pasting of notes in a person’s electronic health record (EHR) without regard to proper scrutiny or updating to reflect that patient’s real-time condition.

The implications of that for medical malpractice and hospital negligence can be staggering and, indeed, concern is growing in the industry that careless copying and pasting is leading to doctor errors and patient harm to an ever-escalating degree.

“It’s an epidemic,” says a doctor and critic at Northwestern University who has studied and written about the practice. “And it’s among people who should know better,” he adds.

The advent of EHRs in medical facilities across the country has been touted for many reasons, including the greater ease it affords for interaction among various medical actors — doctors, pharmacists, lab technicians, medical teams at different locations — and for its expected savings over historically maintained paper records.

A down side has emerged, too, though, and a major component of it relates to the confusion and compromised medical care that has been seen to result from careless carry-over pasting of medical information. That data — which is often outdated — is subsequently seen and relied on by new doctors and medical teams that misinterpret it.

“It’s especially problematic when you have multiple teams taking care of the patient and we’re communicating through the same chart,” says a professor of medicine at Yale University.

Researchers at Weill Cornell Medical College counsel “extreme care” for doctors copying and pasting patient data in EHRs, and the college has issued guidelines concerning its limited-use recommendations.

The bottom line: Text that is being carried forward should always be updated to reflect a patient’s current medical reality.

Source: American Medical News, “EHRs: ‘Sloppy and paste’ endures despite patient safety risk,” Kevin B. O’Reilly, Feb. 4, 2013

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