How to Reduce the Risk of Copy and Paste

Providers should never C&P material they have not read nor vetted for accuracy.

A young Jeopardy! champion died from bilateral pulmonary emboli following a colectomy in January 2021. Following his surgery, it was reported that the surgeon referred to “DVT/VTE Prophylaxis/Anticoagulation” and another note read, “already ordered.” “DVT Prophylaxis” was mentioned in the progress notes, but on analysis, it was determined that the order had never been entered and executed. Although DVT prophylaxis has long been my apocryphal example of dangerous copy and paste, one could certainly envision the phrase, “DVT prophylaxis,” being copied and pasted ad infinitum to the patient’s detriment and demise in this case.

It occurs to me that my email alerts me when I have used the word, attached, in the body of an email without affixing an attachment. I think they should program the electronic health record (EHR) to trigger an alert if any variation of “DVT prophylaxis” is documented in a note if there is no anticoagulation ordered. In fact, there are other instances when this function might be useful, like if antibiotics are alluded to but no order had been placed. The provider would be given the opportunity to rectify the lapse prior to an adverse outcome. But I digress. I am preparing to rail against copy and paste (C&P).

It is not my nature to complain about an issue without offering solutions. This article is going to be referencing Partnership for Health IT Patient Safety’s “Health IT Safe Practices: Toolkit for the Safe Use of Copy and Paste” from February 2016. I strongly recommend reading it and implementing their recommendations.

I like their definition of copy and paste: “data that is volitionally obtained and used elsewhere without having to retype any of the information.” When I teach my two-day course on medical documentation for folks who have gotten in trouble with their Medical Boards, I have them consider why we never used to have this issue in the days of paper records. It would be too time consuming to copy the note from yesterday over into today’s documentation. We would spend a few moments determining what points were critical to be documented today to avoid wasting time. This is, of course, how we are in the pickle we are in now. Convenience is compelling, and it takes only a click of a mouse to copy large swathes of text whereas typing discrete, essential details would take more precious time. Additionally, reviewing what was just deposited into today’s note and revising, editing, and deleting the information to make it accurately reflect today’s situation can be very labor-intensive.

The toolkit includes autofill and autocomplete in the actions which may adversely affect the data integrity of documentation. I will also include prepopulating and templating. All of these may result in inaccurate, inconsistent, outdated, irrelevant, redundant, or incorrect information. Other risks are note bloat (inordinately long notes) and the inability to distinguish new or important information from reused or recycled information.

However, this genie is not going to be stuffed back into the bottle. The toolkit and literature suggest ~80 percent of providers C&P. The toolkit presents a DVT prophylaxis case as an example and then enumerates the risks including erroneously concluding that someone else has completed a critical action, cluttering the record with results without discriminating which ones are productive, impedance of timely diagnosis or treatment, and introduction of medicolegal peril.

When information from a previous encounter or another individual’s record is brought into a record, decisions can be made on faulty information which can result in catastrophe. I had a coder ask me once what to do about an operative note that had, in retrospect, been imported from a previous encounter. From that day forward, the record reflected, “Post op Day 1,” “POD 2,” etc. She wanted to know if she should capture the ICD-10-PCS code for a total prostatectomy in this visit when it seemed to have been paid for in the last visit. What’s that called, friends? FRAUD!

After identifying the risks from C&P, the toolkit proffered its suggestions based on “four safe practice recommendations”:

  • Recommendation A: Provide a mechanism to make copy and paste material easily identifiable.
  • Recommendation B: Ensure that the provenance of copy and paste material is readily available.
  • Recommendation C: Ensure adequate staff training and education regarding the appropriate and safe use of copy and paste.
  • Recommendation D: Ensure that copy and paste practices are regularly monitored, measured, and assessed.

I worked in a system which had adapted their EHR to gray out any text which had been copied and pasted. It was a beautiful, time-saving thing because I didn’t have to slog through reading pages and pages of identical verbiage. The toolkit points out that there are elements that should not be eligible for C&P, such as the signature block and time stamp. The institution will need to work with their vendor to design the solution which is right for them.

As a physician advisor, I was once tasked with educating a consultant who had the practice of copy and pasting the entire history and physical examination from the admitting service, including the plan with line item, “Consult ME.” This is another example of fraud – attempting to pass off someone else’s work product as your own. Recommendation B relates to the behind-the-scenes audit trail that exists in the EHR. The author of documentation is always digitally ascertainable.

Recommendations C and D require providers to be educated on acceptable uses and applications of C&P. Policies and processes regarding C&P must be put into place and providers’ utilization must be audited, measured, monitored, and corrected, if necessary. I was a bit shocked to see the statistic that only 24 percent of hospitals have a copy and paste policy in place, but then I recalled that I was the self-appointed author of my own system’s policy when I was a physician advisor. The toolkit provides some sample policies and procedures to avoid having to reinvent a wheel.

The group recognized that EHRs and workflows vary, and that there is no one size solution that fits all. They offer several suggestions and options, and there is a list of references and valuable resources at the end of the toolkit. Pitfalls and considerations regarding their recommendations are also present in the toolkit. I endorse the use of the provided tools, action plans, and checklists to assist organizations, their providers, and their vendors in assessing their risk from C&P and devising actions. The task force even has shared an adaptable PowerPoint presentation.

I’ll share a little exercise I do with providers with you. First, I ask them to raise their hands if they like the convenience of copy and paste. Then I ask them to raise their hands again if they like reading other people’s copy and paste. Sheepishly, they look at me as it dawns on them that one man’s convenience is another man’s impediment to taking efficient care of patients. I think experiential learning is superior to lecturing.

Providers should be instructed to never C&P material they have not read and have not vetted for accuracy. They should not copy elements that contribute to a billable CPT® service unless the service is reperformed as medically necessary. This is going to be even more important in 2023 when medical decision making becomes the sole component for professional billing. Copy and pasting the entire assessment and plan as is common practice today will be verboten.

If they MUST use copy and paste, they should transition to thinking of it as COPY and EDIT. Everything that the record says today must be correct today. My advice is to encourage providers to put MENTATION back into their documentation.

Programming Note: Listen to Dr. Erica Remer report this story live today during Talk Ten Tuesdays with Chuck Buck at 10 Eastern.

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Erica Remer, MD, FACEP, CCDS, ACPA-C

Erica Remer, MD, FACEP, CCDS, ACPA-C has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. As physician advisor for University Hospitals Health System in Cleveland, Ohio for four years, she trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016. Dr. Remer is a member of the ICD10monitor editorial board and is the co-host on the popular Talk Ten Tuesdays weekly, live Internet radio broadcasts.

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