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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.

My general internal medicine practice is equidistant from the three academic institutions and a Veterans Administration facility, and thus I have patients who receive primary, secondary and tertiary care at each of these institutions.

The notes I receive back from one of these organizations are hands down the best of the four institutions. These notes are personal, concise, precise and clear. If the patient had a complicated outpatient work-up the communicating physician will send a problem-oriented summary of the patient’s symptoms, the work-up, the conclusion and the recommended next steps. There is a clinical narrative with clear communication of the patient’s unique story and the medical decision-making. Furthermore if the patient saw more than one physician, the note I receive integrates the impressions of all of the physicians.

For my patients hospitalized at this institution I especially value the discharge medication list, which is broken down into fields for continued medications, modified medications, new medications and discontinued medications. In most circumstances the patient has also received a copy of the inpatient and outpatient notes and the medication list.

From the other organizations the communication is rather more like a “ransom note,” a multi-font collection of structured text entries, pieced together with imported labs and x-ray results into a hard-to-read document, typically 6 pages of structured text, with an emphasis on billing justification and compliance language. Scanning through these lengthy documents for the “meat” of the note I struggle to find a coherent story (but I readily see what type of learner the patient is, and what part of the visit the attending was present for and other billing and compliance information.) Three different EHRs are represented. Here is a typical emergency room note:

The patient presents with palpitations. The onset was just prior to arrival. The course/duration of symptoms is resolved. Character of symptoms skipping beats. The degree at present is none. The exacerbating factors is none. Risk factors consist of none. Prior episodes: none. Therapy today: none. Associated symptoms: near syncope

Transcriptionists are being replaced by physicians for cost reduction, a calculus that doesn’t consider reductions in patient safety and quality, or lost physician productivity and well-being.

This “savings” in transcription costs also comes at a cost to the clinicians who subsequently read through multiple pages of low value text to find the kernel of useful information. And because the person documenting the care spent considerable time processing through the drop down boxes, less effort has been applied to the assessment and plan, often leaving the receiving physician in the dark when trying to pick up the thread of care.

I have always appreciated the care my patients receive at the first institution, not just for the care itself, but for the systematic, reliable communication I receive back about my patients. I recognize that having one physician summarize complicated care across many specialties, and having dictated notes is an expense, but it is an expense that makes a difference in the care of patients. Replacing transcriptionists with physicians is a fool’s bargain.