How copy and paste in electronic medical records affects patient care

With many hospitals and medical providers still in the early adoption stages of EHR, objections or problems with the various systems are still just coming to light. However, one particularly growing concern is providers using the copy-paste or copy-forward function in patient records. This is a shortcut that many physicians have found to be handy after the implementation of the new system, however using it actually can violate patient confidentiality and HIPPA rules, and lead to fraud or malpractice lawsuits and federal or payer audits. More importantly, the misuse of these functions can negatively affect patient care.

In using copy-forward or copy-paste incorrectly, physicians or nurses can affect patient care in several ways. The first problem is when providers copy more information than what is actually relevant – say pages of labs from an unrelated issue – and paste it with their notes. This creates “note bloat” in the EMR system, which makes it more difficult for other providers to interpret the last physician’s notes and decipher what the patient’s current issue is and what issues listed have already been resolved.

A more serious concern is when information is copied from one patient’s record to another. This can lead to incorrect information being stored on a patient’s EMR record, and can also lead to HIPAA violations if any of the original patient’s information is stored on another patient’s chart.

In addition, problems arise when the copied note includes errors, for instance if a surgeon indicates that the patient’s left knee is being operated on, when in actuality it is the patient’s right knee. Although the surgeon can go back and fix their mistake on the patient’s original record, if the note has been copied by other providers the wrong information is then contained within the patient’s current chart. This can lead to the improper care or diagnosis of a patient, and has the potential to lead to malpractice lawsuits.

Copy-pasting or copy-forwarding can also lead to the patient or insurance company being billed incorrectly, leading to payer audits and fraud lawsuits. For instance, if a physician sees a patient but doesn’t complete a new physical exam, and instead copy-forwards a physical exam provided by another doctor, the medical billing team doesn’t know the difference and can bill the patient or insurance company for a new physical. This is clearly unethical, and the patient or insurance company then has grounds to investigate fraud or file a lawsuit.

As patient care grows more intertwined with technology, medical facilities need to be aware of the potential hazards created when using shortcuts in these technological systems, and additional efforts need to be taken to reduce these shortcuts.

Elizabeth Hipp is Social Media Director, Transcription Outsourcing, LLC.  She blogs at the Transcription Outsourcing Services Blog.

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