![]() Furthermore, inappropriate copy-pasting could facilitate attempts to inflate claims and duplicate or create fraudulent claims.” 9 The report warned that “when doctors, nurses, or other clinicians copy-paste information but fail to update it or ensure accuracy, inaccurate information may enter the patient’s medical record and inappropriate charges may be billed to patients and third-party health care payers. In 2014, the Office of the Inspector General for CMS released a report titled “CMS and Its Contractors Have Adopted Few Program Integrity Practices to Address Vulnerabilities in EHRs”. may use tools like copy-paste to more efficiently author notes that meet the real or perceived requirements of stakeholders from billing, compliance, and legal departments. hospitals using the same EHR, Dowling and colleagues found that ambulatory notes in the United States are 4x longer than notes written in other countries. is likely a primary driver of clinical note length. The complex payment and medicolegal environment in the U.S. Wrenn and colleagues found that more than half of the text in EHR progress notes originated from prior notes accounts, 7 and a 2017 study by Wang and colleagues found that 82% of text in inpatient progress notes was copied or generated by a template. ![]() ![]() 4- 6 In addition to the potential for harm that arises when notes contain inconsistent and outdated information, note bloat may result in salient information becoming buried or lost. The “note bloat” phenomenon, where clinical notes balloon in length as large amounts of nonessential information are inserted, has been decried by experts as both annoying and dangerous. Recognizing the widespread use of copy-paste in EHRs and the associated patient safety and compliance risks, the Partnership for Health IT Patient Safety provided four recommendations aimed at health information technology vendors and healthcare delivery organizations: “1) Provide a mechanism to make copy and paste material easily identifiable 2) Ensure the provenance of copy and paste material is readily available 3) Ensure adequate staff training and education 4) Ensure copy and paste practices are regularly monitored, measured, and assessed.” 3 While the first two recommendations have become standard functionality in EHR systems such as Epic Hyperspace (Epic Corp., Verona WI), the others-staff training/education, and regular monitoring of copy-paste practices-are more difficult to adopt.Īt Geisinger, an integrated academic health system with over 4,100 providers on the medical staff, we developed a pragmatic approach to assess the use of copy-paste in aggregate, and also provide individual training opportunities by including providers’ copy-paste usage statistics into the ongoing professional practice evaluation (OPPE) process that is required for hospital accreditation. Given the challenges that contribute to provider burnout, including increasing documentation requirements and poor electronic health record (EHR) usability, 1, 2 copy-paste is a welcome function that allows clinicians to author more comprehensive notes more quickly. ![]()
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