The electronic medical record (EMR) has enormous potential to improve the quality and safety of US healthcare.1 Electronic note writing by physicians and nurses enables the use of time-saving computer editing functions which include the copy and paste function. Copy and paste practices by healthcare clinicians aims to not only reduce time but also enhance efficiency in medical documentation.2 In today's complex care environment, these documentation practices create several issues including accurate tracking and identification of original authorship, and may lead to cognitive bias. The term note bloat is a common phrase used to mean that a note that has become difficult to review and understand because of the excessive amount of copying and pasting. For researchers, it may also include errors in data extraction and bring into question the validity of the data. The practice of copy and paste has resulted in new safety risks and legal concerns. Recently, the ECRI Institute (formally the Emergency Care Research Institute) released a white paper/toolkit on the safe use of copy and paste.3 The ECRI recognizes the practice and benefits of being able to copy and paste, and the white paper concentrates on minimizing the patient safety risks instead of trying to delete the practice altogether. Studies have shown that copy and paste is used in healthcare frequently and is now appearing in medical malpractice litigation.2,4,5

WHAT IS COPY AND PASTE?

There are many terms describing copy and paste: copy and paste, copy functionality, cloning, carry forward, auto fill and data replication, and reuse.2,6 All the terms refer to copying from one area of a medical record to another and often by another person other than the originator of the note.

PREVALENCE

There is a general sense among healthcare practitioners/clinicians that documentation of patient encounters is aided by using content importing technologies.2 These include copy and paste. Inappropriate reuse of information may result in reliance on information that is inaccurate, incomplete, or outdated and lead to patient safety issues. The body of literature assessing the prevalence and clinical impact of copy and paste has been building for over 10 years. An early study into the issue was conducted at the Veterans Administration between 1993 and 2002, revealing over 2000 notes contained copied text equating out to a 9% prevalence.7 In 2009, a survey of medicine and pediatric residents and faculty also revealed that 89% of them who documented electronically made use of the copy and paste function.2 A later study in 2013 in an intensive care unit at an academic hospital revealed that 82% of notes from residents and 74% of notes from attending physicians contained 20% or greater copied information when analyzing the assessment and plan alone.8 Most users of EMRs acknowledge that documentation using content imported technology was prone to inconsistency and inaccuracy.8

BENEFITS OF CONTENT IMPORTING TECHNOLOGIES: COPY AND PASTE

The benefit of the EMR is well known and documented in the literature.2,9 However, the benefit of copy and paste has not been well studied. Most clinicians feel that the use of copy and paste enhances the documentation of a patient visit or consultation.9 Additional benefits believed by clinicians include the auto fill of clinical data into a template, assisting with clinical research. With the increase in complexity of patient's entering the healthcare system today, the use of copy and paste has been identified as being beneficial with helping to track the constant flow of active and inactive patient problems.9

PATIENT CARE RISKS

Weis and Levy6 highlighted the risks to patient care using copy and paste.

1. Inaccurate recording of patient's symptoms and hospital journey

2. Incorrect insertion of data from other parts of the record

3. Repetition of expired, irrelevant, or incorrect clinical information

4. Bloated notes distracting reader from essential facts and data

5. Use of incorrect template for patient visit

6. Lack of consistency of documentation

7. Diagnostic bias

Healthcare clinicians have suggested that to mitigate risk, there should be a push toward a more progressive model for the EMR, with recording of data once and encoded for later use, and where the notes entered should be patient focused around their problems.10

REGULATORY ISSUES

The use of copy and paste along with other content importing technologies has raised questions around professional billing and the quality of data being collected on patient visits and consultations.11 There are also specific rules around documentation for Medicare billing, specifically "cloned" documentation.12 The major concerns center around cloned notes; excessively long notes, which include diagnostic test data; copying of data written by unlicensed persons; and copying of examination findings and outdated histories.6

DOCUMENTATION IN THE EMR: WHAT IS RECOMMENDED TO REDUCE RISK AND INCREASE ACCURACY WHEN USING COPY AND PASTE?

Members of the Association of Medical Directors of Information Systems (AMDIS) have proposed guiding principles for electronic documentation and ECRI has released a toolkit for the safe use of copy and paste 3,13 A summary of their recommendations is as follows:

AMDIS:

1. Document each patient visit/consultation with the minimum data necessary that are relevant to that visit only. Each documented encounter must meet legal, accreditation, and regulatory criteria.

2. Collect data and record/display it in a way that will meet the needs of all those who will read it, including other providers and regulatory bodies. This will ensure that the communication between providers is accurate and timely.

3. Specific sections of the patient's clinical assessment should reflect the work product of the final author and not be carried forward; these include (a) history of present illness, (b) review of systems, and (c) physical examination and assessment.

4. Each provider and the healthcare facility/organization must keep all patient information private and secure both physically and digitally as per the Health Information Portability and Accountability Act of 1996.14

ECRI:

Toolkit for the Safe Practice of Copy and Paste (some functions are directed toward vendors of the EMR for solutions)

1. Recommendation A: Develop a system to make copy-and-paste material easily identifiable. Actions for implementation: Monitor compliance, develop a way to easily identify copy and paste in notes; have a policy that states what can be copied and pasted and what cannot.

2. Recommendation B: Ensure that the origin of copy-and-paste material is readily available. Actions for implementation: Track regulatory compliance around copy and paste; develop a way to easily identify the original source of the information that is being copied.

3. Recommendation C: Ensure that there is a system in place for staff training and education. Actions for implementation: Every facility/healthcare organization should develop their own audit policy to monitor the use of copy and paste and to enable a report out on a regular basis to facilitate additional education requirements and or action.

The American College of Physicians have also released a position paper on clinical documentation in the 21st century calling for further research in the following areas15:

1. Identifying best practices that will enable systems and providers/clinicians to improve the accuracy of the information that needs to be documented as well as exploring the value of information presented to other users of the EMR.

2. Study the whole process of authoring of medical notes that includes the development of instruments that will automate documentation without reducing the quality of the note and at the same time facilitating the "right" behavior.

3. Study the best way to prepare/educate the new clinician and the existing clinician for the rapidly growing use of information technology and how the system should be used to enhance the workflow of the clinician without introducing additional risk.

4. Study the best methods to use to disseminate professional standards of clinical documentation and best practices to enable all clinicians to benefit and replicate in different healthcare systems for possible adjustments.

DISCUSSION

The cost of healthcare fraud is between $75 billion and $250 billion, based on 2009 figures released in a 2014 report by the Department of Health and Human Services: Office of Inspector General.16 In the report, it highlights that 2 documentation practices in the EMR that could be used to commit fraud: copy and paste and over documentation. In 2013, only 24% of hospitals had a copy/paste policy in place.17 The electronic environment has produced the function of copy and paste, and healthcare providers have used the function as a shortcut to ensure that their documentation is complete while saving time. The ECRI and AMDIS both recognize that the practice cannot be eliminated and have addressed the issue, including acknowledging to need to work with vendors for possible solutions.3,13 Before any solution is developed, the basis of why providers copy and paste needs to be understood in an organization. Weis and Levy6 outlined many healthcare organizations that have developed policies centered on the do's and don'ts of content importing technologies. Of the 10 hospitals/systems outlined, the don'ts were not all the same and not all stated cloned notes were prohibited. Regardless of the tools used by the clinician, all healthcare organizations would agree that the individual signing the note acknowledges that he/she is responsible for the whole note.

Defining what constitutes a high-quality note remains a challenge. Some suggestions from the literature include legibility, accuracy, thoroughness, and compliance with administrative documentation standards.18,19 The Physician Documentation Quality Instrument suggests measuring quality of the note by the following: must be up to date, accurate, thorough, useful, organized, succinct, and internally consistent.19 Government payers such as Medicare has begun to define what a quality note is not and has determined that cloning is prohibited and would be cause for payment denial.17

THE IMPACT OF THE CLINICAL NURSE SPECIALIST

Clinical documentation is entangled in both professional and hospital reimbursement in the era of healthcare reform. Hospitals require comprehensive documentation to meet coding, reimbursement, and quality metrics. A patient's severity of illness and risk of mortality affect publically reported hospital rankings, further encouraging the need to document everything. The EMR should be patient centric, with the future focusing on improved data management. The clinical nurse specialist (CNS), in her or his role at the medical center and outside in the community setting has a responsibility to become engaged with improving the management of patient data to ensure that the patient is protected and the healthcare organization is appropriately reimbursed by all payers through accurate documentation that meets regulatory requirements. As an advanced practice registered nurse, the CNS has the ability to role model the best practices identified in the literature (ECRI and AMDIS) and to facilitate discussion with members of the multidisciplinary team around the practice of copy and paste. Often, the CNS is the common thread for members of the team and is viewed as the informal leader for the disciplines involved in patient care. Commencing with the bedside nurse, the CNS should review documentation to reinforce and educate on best practices for ensuring accuracy in the medical record and involve them in developing a policy on EMR documentation outlining the registered nurse, medical physician, and other disciplines responsibilities for documentation. Auditing for compliance with the policy can be achieved with the CNS collaborating with other members of the management team to promote the performance improvement process that may be required when issues arise.

Amidst the backdrop of increasingly complex healthcare environments, compounded by the growing ubiquity of health information systems, the CNS can help to balance the need for documentation automation with critical thinking by partnering with nursing informatics experts to determine what elements of a patient's chart are clinically appropriate to copy and paste. In addition to their contribution in the design of documentation systems, the CNS has a critical role in providing ongoing education about the dangers of misusing these features, while developing feedback loops with frontline caregivers to learn from their workarounds. The CNS is a critical member of the team, as it takes a village to develop and implement systems of monitoring practice and documentation while optimizing the use of electronic systems in providing evidence-based care.

CONCLUSION

With the growing use of EHRs in hospital systems and EMRs across the continuum of care to improve the quality of clinical documentation and transparency of information among caregivers, there has been an emerging body of empirical evidence of the challenges faced by clinicians in using these systems. Driven by these structural and process challenges, workarounds have been developed by users to overcome software limitations and gaps. As EHR systems address these workarounds and manual processes through features such as copy/paste, there needs to be attention paid to the unintended consequences of these solutions-ranging from chart inaccuracies when the wrong data are copied and pasted to within a patient's chart or to another patient to the deterioration of clinical workflows when things like vital signs are merely copied forward without physically checking on the patient. All healthcare organizations will need to have polices in place to address these.

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