Us­ing cau­tion with copy and paste

Modern Healthcare - - BEST PRACTICES - By Adam Ruben­fire

Ctrl+C & Cl­trl+V: They’re bet­ter known as “copy-and-paste.”

They are fre­quently used key­strokes that are sup­posed to of­fer a quick and easy way to repli­cate text. But care­less copy­ing and past­ing could to lead to deadly er­rors in the health­care in­dus­try and un­for­tu­nately, some of those mis­takes may be fly­ing un­der the radar.

Over the past few years, the not-for­profit ECRI In­sti­tute, a fed­er­ally cer­ti­fied pa­tient-safety or­ga­ni­za­tion, has been warn­ing hospi­tals about the er­rors that copy-and-paste can in­tro­duce to elec­tronic health records. Staff use it to move data or sum­maries be­tween records or be­tween dif­fer­ent parts of a record. Er­rors can oc­cur when an em­ployee copies the wrong text, cuts off text they had in­tended to copy or copies text into the wrong field. That can lead to missed drug al­ler­gies, in­cor­rect dis­charge in­struc­tions or even flawed lab re­sults, just to name a few worst-case sce­nar­ios.

Ide­ally, lab re­sults or imag­ing stud­ies from third par­ties or other units of the hospi­tal would flow di­rectly into the EHR through in­ter­faces with other sources with no need to copy-and-paste, but that’s not al­ways the case in hospi­tals that have legacy soft­ware sys­tems or poor in­ter­op­er­abil­ity.

Be­tween 2013 and 2015, the lat­est data avail­able, ECRI’s data­base re­ceived only 12 re­ports of copy-and-paste-re­lated er­rors, but re­searchers be­lieve that num­ber is highly un­der­re­ported be­cause the mis­takes are ob­vi­ous to well-trained staff and are quickly cor­rected, or be­cause they’re re­ported to other de­part­ments in­stead of the hospi­tal’s safety staff. In­di­vid­u­als are also un­likely to report their own mis­takes, said Lor­raine Pos­sanza, a pro­gram direc­tor at ECRI.

ECRI, along with re­searchers at the Na­tional In­sti­tute of Stan­dards and Tech­nol­ogy, or NIST, aren’t ask­ing providers to stop us­ing copy-and-paste, but rather to be smarter about it. Last year, ECRI re­leased rec­om­men­da­tions on how providers and EHR ven­dors should guard against these er­rors.

First, providers and ven­dors should make it easy for users to iden­tify con­tent that was copy-and-pasted. So ven­dors or hospi­tal IT pro­fes­sion­als should look into cre­at­ing iden­ti­fiers for copy-and-pasted con­tent, such as the abil­ity for copy-and-pasted text to change color when it’s hov­ered over, a sep­a­rate pane for copy-and-pasted text or dif­fer­ent for­mat­ting for that text, Pos­sanza said. Any function like this should be au­to­mated.

Mech­a­nisms cre­ated by a hospi­tal or ven­dor to iden­tify copy-and-pasted con­tent should also iden­tify the con­tent’s source, along with the con­text, author, time and date of that doc­u­ment, ac­cord­ing to ECRI. In their Jan­uary anal­y­sis of ECRI’s rec­om­men­da­tions, NIST re­searchers call this in­for­ma­tion the “chain of cus­tody,” and rec­om­mend that any such meta­data be pre­sented in a way that isn’t over­whelm­ing to users. Crowd­ing of data could lead to er­rors, said Lana Lowry, a project lead at NIST and a co-author of the anal­y­sis.

There’s an even more im­por­tant rea­son why those er­rors could oc­cur. “The rea­son peo­ple copy and paste is be­cause it’s sim­pli­fy­ing their task,” Lowry said. “But the rea­son why they’re look­ing for sim­pli­fi­ca­tion is be­cause they’re over­whelmed,” so so­lu­tions shouldn’t over­whelm them fur­ther, she said.

Epic Sys­tems Corp.’s EHR sys­tem warns providers who use copy and paste. It also iden­ti­fies the pa­tient record where the copied text came from. Most Epic users aren’t high­light­ing text and copy­ing it like the av­er­age com­puter user. Rather, they of­ten use built-in “copy” but­tons that al­low users to copy a spe­cific part of a record such as the phys­i­cal exam or med­i­cal his­tory. That can guard users who might fail to high­light the en­tire note they’re try­ing to copy. If a user copies dis­crete data such as vi­tal signs from an ear­lier record, Epic’s sys­tem will also up­date that data.

Providers should train staff to use these func­tions to their fullest ca­pa­bil­ity. EHR ven­dors should warn providers against us­ing copy-and-paste in cer­tain ar­eas be­cause of the se­ri­ous risks that come with an er­ror, Lowry said.

Providers and ven­dors should reg­u­larly mon­i­tor and as­sess providers' copy-and-paste habits, ac­cord­ing to ECRI. Epic pro­vides that data in hopes of one day help­ing providers un­der­stand how of­ten they should be us­ing the func­tion­al­ity. It’s im­por­tant to re­tain the abil­ity to at least copy things that don’t of­ten change from visit to visit, said Dr. Sam But­ler, Epic’s chief med­i­cal of­fi­cer.

“There is a sweet spot for how much we should copy and how much we shouldn’t copy, and I don’t think we know that yet,” But­ler said. “There are peo­ple who say you shouldn’t be able to copy any­thing for­ward—that would be an aw­ful bur­den.”

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