The use of Electronic Health Records (EHR) for documenting patient data is the norm among today’s medical providers. Nationally, 87% of office-based doctors use EHR systems of some type. In the District of Columbia the usage rate is 76.4%, in Maryland, it is 82.5%, and Pennsylvania’s usage is 83.4%. According to data from The Doctors Company, roughly 64% of EHR-related claims of medical malpractice are the result of user error. In today’s litigious healthcare environment, providers should strive to minimize mistakes when working with these systems.
Most EHR systems have fields that need to be populated with data following a patient visit; this may apply even when no real changes have occurred. Many physicians find this unnecessary data entry to be pointless and some may simply choose copying and pasting the previous note and making changes where needed, which can lead to problems. Physicians have long complained that EHR systems slow them down and will attempt to use shortcuts to save some time, but these ultimately can create errors.
When a physician uses copy & paste from a prior note, there is the possibility that they will fail to make the needed changes. The use of copy & paste is most commonly seen when generating history and physical (H&P) notes. Sharona Hoffman, a law professor at Case Western Reserve University Law School in Cleveland, Ohio, explains that copying and pasting from a prior medical record to create a new one is never a good idea. She says that the practice of copy and paste is occurring at a “fever pitch” currently. Too often, the copied information is inapplicable, inaccurate, or outdated, which can render the validity of the data in a practice’s EHR as being less credible in a malpractice case.
Another problem that results is that copying and pasting begins to create a high volume of unnecessary notes. This can lead to pertinent information being lost amid the notes and simply expands the volume of outdated information. Other clinicians who must reference these notes later on find themselves sifting through too much unnecessary information to find what they are looking for. A plaintiff attorney who receives such reports during discovery will quickly recognize that the copy & paste method was used and may question the overall reliability of the records and whether the physician is truly engaged in patient care.
Historically, physicians have faced liability for problems that could have been prevented if a patient’s medical records had been maintained in an accurate manner. In the case of Short v. United States, a doctor was facing a claim of failing to diagnose prostate cancer. The physician was deemed to have violated the standards of care for failing to check the prior notes about the patient, which would have revealed critical information. Doctors are encouraged to take a moment to accurately document each patient visit in the EHR. Also, many systems do allow for the copy & paste option to be disabled.