Copy and Paste in the Medical Record: A Top EHR Danger

It’s something people have done every day in their personal and professional lives since computers had mouses: copy and paste. But when it comes to medical notes in patient charts, copying and pasting carries risks of confusion, patient harm, and liability for providers. If the facts that are being pasted are no longer accurate, then providers may be relying on outdated information for diagnoses and treatment plans. Attorney Amy Germond is a claims manager at CRICO, the malpractice insurance program for the Harvard medical institutions and their affiliates. And Germond says, it happens:

“Overall, copy and paste as a contributing factor in a malpractice case is rare. However, when it does come up in a case, it tends to be a factor in which we close more of those cases with payment than without it.”

Data gathered from across the country through CRICO’s Candello division indicate a copy and paste problem. Over a recent five-year period, malpractice cases with an electronic health record user issue closed with a payment to the plaintiff about 23 percent more often than cases without an EHR user issue. And the ones that feature copy and paste issues are about 18 percent more likely to close with payment than other EHR cases.

To illustrate how copying and pasting part of the record can lead to harm, Amy Germond describes a real case. The patient was an 85-year-old woman with diabetes and peripheral neuropathy who was referred to a podiatrist with a blister on her toe. The podiatrist decided to place her in an ortho-wedge boot to ease the weight on the blister.

“But the problem in the case was with regard to the patient’s history, the podiatrist relied upon a note that he copied and pasted which stated that the patient walked regularly. When in reality—because of her neuropathy—she was developing gait instability and she was actually advised to walk with a cane when ambulating. And unfortunately, we learned during the course of the litigation that this particular patient didn’t really like using her cane, especially in public. She tended to use it more at home.

So because she was out at a medical appointment, she did not take the cane with her. And because this podiatrist wasn’t aware of the gait instability that she had developed (relying upon information that was out of date in his note) he gave her this boot which would have been the standard of care to treat the blister, but didn’t really consider the fact that she was now having difficulty ambulating without a cane, didn't bring the cane, didn’t have anyone with her at this visit.”

The patient then left the appointment in the boot, walked to her car in the parking lot, and fell. She broke vertebrae in her back. While she was in the hospital, she developed pneumonia and died. Review of the medical record found that the podiatrist note was identical to a previous note from five years earlier stating that the patient “walks regularly.” This narrative in the EHR was not updated.

“And what made the difference in this case was, if I think the podiatrist had been more aware that her ability to ambulate had in fact changed, he might’ve used a different thought process and maybe telling her to wait to put the boot on until she was at home. Or maybe if he looked at her ability to ambulate, maybe she wasn’t even a candidate for the boot. But because this information was inaccurate and relied upon, we had this unfortunate outcome.”

Dr. Adam Schaffer is Senior Clinical Analytics Specialist at CRICO, and a hospitalist at Brigham and Women’s Hospital in Boston. Most of the EHR cases in the study set are from the ambulatory setting. Dr. Schaffer says care in these locations more often involves diagnoses rather than procedures. If a patient chart contains material that was copied and pasted, sometimes multiple times, the provider may be misled.

“For example, a visit may involve a general internist evaluating a constellation of seemingly disparate symptoms and attempt to arrive at a diagnosis. With cognitive care encounters such as this, the clinician is often drawing on multiple pieces of information in the EHR. And so if this information is incorrect, outdated, or unavailable, then it might make it harder to arrive at the diagnosis.”

Dr. Schaffer and attorney Germond also say that billing requirements can push clinicians to put more in the record than they would otherwise, in order to be reimbursed. Providers in other countries document less and are more satisfied with their EHR’s efficiency than clinicians in the U.S. Dr. Shaffer explains that entering too much patient information beyond what is needed for clinical issues can undermine care.

“So one can sort of get in the mode of ‘I need to get through the day, let me make sure I fulfilled all the requirements for the documentation.’ And it's easy to pull in information that has already been entered. And that's not necessarily problematic to do, you just need to be thoughtful about it. So you need to make sure if you're pulling in a family history, especially as part of an admission note, when was that family history updated? Importing a family history that someone entered from a week or two ago is very reasonable, but importing a family history from five years ago, especially if you don’t actively update it, that's more problematic.”

Dr. Schaffer recommends that clinicians document their reasoning and even their uncertainty. But don’t make subsequent treating providers wade through an ocean of material in the record.

“One thing clinicians can do, is to make it easier for other clinicians to find the information that is likely to be most important to them. This can mean including information that is needed for billing—but is less clinically relevant—in a separate section at the bottom of the note. It can also involve putting the most critical information, such as the assessment and plan, right at the top, where you can see it immediately.”

Germond says that to minimize the risks of mistakes based on inaccurate copied and pasted text, clinicians should consider limiting the practice when the information needs updating. And if something goes wrong, she says documentation that demonstrates the provider’s clinical rationale and shows the clinician was reasonable is more important than trying to make the documentation perfect.

“I think sometimes with cutting and pasting, you might just move that information forward, but you want to really make sure, is it still accurate? Is that information still accurate that I have in my note? So I think that's the most important piece: no matter how your note is created, it's really important to make sure it's accurate and that it accurately reflects your care and treatment and decision making. So, at the end of the day looking back at that note—which is the contemporaneous information that jurors really rely on in these cases—it shows that you are being reasonable.”

For more on this topic, you can enroll in the free CRICO-sponsored CME course, Documentation Risks in Malpractice Cases: Copy & Paste Risks.