With the accelerated adoption of electronic health records (EHRs), there is growing recognition of the benefits associated with the use of these technologies – reduced medical errors, faster access to complete information, more efficient communications among busy clinicians, and increasing patient engagement in their healthcare decisions. At the same time, there is a dialog taking place among all stakeholders on the issues related to busy clinicians taking advantage of data re-use capabilities to avoid re-entering identical information as they create their encounter documentation.
The EHR Association strongly believes that data re-use tools are critically important for clinicians, provide clear benefit for patients and, when used appropriately, enable accurate legal and financial recording workflows for providers.
Before delving into the pros and cons of data re-use, it is important to recognize that there are many facets to what is generally referred to as “copy/paste” (sources noted):
- Copy functionality: reproducing text or other data from a source to a destination (American Health Information Management Association (AHIMA). Appropriate use of the copy and paste functionality in electronic health records [online]. 2014 [cited 2015 Aug 26], http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_050621.pdf).
- Copy and paste: action performed either by keyboard command (e.g., Ctrl + C to copy and Ctrl + V to paste) or with a mouse; selecting data from an original or previous source to reproduce in another location (Association of American Medical Colleges (AAMC) compliance officers’ forum: electronic health records in academic medical centers [online]. 2011 Jul 11 [cited 2015 Aug 26]. https://www.aamc.org/download/253812/data/appropriatedocumentationinanehr.pdf).
- Cut and paste: removing or deleting the original source text or data to place it in another location (e.g., Ctrl + X to cut and Ctrl + V to paste) (AAMC, as above). (NOTE: We believe that deleting any portion of a patient’s electronic record should never occur so will not address this capability here.)
- Cloning: duplication of a note (Weis JM, Levy PC. Copy, paste, and cloned notes in electronic health records: prevalence, benefits, risks, and best practice recommendations. Chest Mar 2014;145(3):632-8. PubMed, http://www.ncbi.nlm.nih.gov/pubmed/24590024).
- “Whole note cloning”: copying patient notes from one visit to the next; copying a note from one patient encounter to the next with little or no editing (Terry K. Redesign EHRs to fit clinical workflows, ACP says [online]. 2015 Jan 12 [cited 2015 Aug 26], http://www.medscape.com/viewarticle/838019).
- Carry/copy forward: bringing forward a portion of a note or an entire old note (Weis and Levy, as above).
- Auto-fill: automatically draws data from another part of the record and inserts it upon a specific command
- Auto-complete: automatically matches text and provides one or more options
We recognize that there are competing viewpoints regarding the use of these capabilities. On the positive side, the ability to reuse text saves time for clinicians in documenting care, and potentially improves data quality by eliminating the need to re-key text. These contributions to improved clinicians’ satisfaction with use of their EHRs cannot be undervalued. On the other hand, there are risks associated with inadvertently copying information that is not relevant or accidentally copying into the wrong record, and the patient safety component of this conversation deserves further exploration.
One additional question raised is whether and how to indicate data provenance – i.e., when was the original data entered into the patient’s record, by whom, and/or at what care delivery site? Some EHRs may have space limitations such that including information on data provenance forces users to go through additional pages in the clinical workflow. Further research is required to better understand what will work most effectively for both end-users and health information management professionals to indicate, store, and assess the provenance of copied/pasted content.
The Association believes that this topic is most appropriately considered in the broader discussion of usability, as EHR developers, provider organizations, and regulators seek to address perceived obstacles to effective, efficient workflows and better end-user satisfaction with their EHRs. Of value to clinicians are speed, accuracy, and completeness of the record to properly document their interaction with the patient. Proper documentation includes the ability to provide a summary to the patient, comply with various third-party billing requirements (e.g., Medicare), and to persist a legal record of what was and was not done.
Organizations like the ECRI Institute (https://www.ecri.org/Resources/HIT/CP_Toolkit/Toolkit_CopyPaste_final.pdf) and the American Health Information Management Association (AHIMA, http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_050621.pdf) have published their guidelines in attempts to give providers parameters around which to make implementation decisions and set organizational policies relative to data reuse features. While the Association supports these efforts to advance the conversation regarding safe practices related to such functions as they are implemented in EHRs and other health IT, we believe that further analysis is needed to better understand how these features are being used today, whether there are any specific patient safety implications, and what best practices can be applied across different healthcare environments using different EHRs.
Accordingly, EHR Association members have been working with provider organizations, as well as their own customers, to better understand the issues that are perceived to impede usability, and to develop best practices related to implementation decisions, end-user training, and organizational policies that can impact workflows and clinicians’ perceptions of their EHRs and other health IT. We believe that these collaborative efforts are important in understanding potential patient safety risks, as well as identifying user-centered design best practices.
Frequently overriding these considerations, however, are organizational policies that are put in place to guide clinicians on how to both take advantage of the efficiency of data reuse features and ensure that they are used appropriately to create accurate and clearly understood clinical notes. Given the variations and implications of how these functions can be implemented and used, we suggest that recommendations for adoption are best promulgated by the industry more broadly, with EHR Association member companies and other health IT suppliers determining how best to implement them in their products, in consultation with and based on their experiences with their customers.
The EHR Association will continue its collaboration with provider groups, standards development organizations (SDOs), regulatory bodies such as the National Institute for Standards and Technology (NIST), and experts in human factors engineering to better understand the broader challenges and opportunities to improve workflows and end-user experiences. It would be a mistake to ban the use of features that are important to clinicians, as we clearly need more time and experience to develop best practices in the area of data re-use.