Is cut and paste in EHR software really such a bad thing?

The following is a guest blog post by Dr. Michael West. I recently met Dr. West and was really impressed with his approach to EHR. After reading a few of his comments on the site, I asked if he was interested in doing some guest blog posts. This is the first of what I hope will be many more blog posts by Dr. West.

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009.

When, I was in residency at a large health system in Pennsylvania, several of the residents and interns got into the habit of templating hospital notes on their home computers the night before they would go in to see patients who were chronic players with multiple medical problems who would often stay for long times in the hospital. I’ll openly admit that I was one of the many who bought into the perceived need to make things more efficient in order to get out of the hospital sooner and have a better home life. The concept was simple: design a pre-templated note for each chronic patient, detailing the plans (which would rarely, if ever, change), and then save it and mass produce at will. Of course, this did not go over well with our purist administration who were in charge of ensuring the highest quality, authentic notes for each patient on each day. In their correctness, they noted that sometimes these notes would be put into patient charts without those small changes that would, in fact, take place from day to day, thus resulting in erroneous documentation.

Now, years later, in the world of EHRs, there seems to be a push-back against the “cut and paste” concept. I know this is out there for two reasons: one, because I have read a blog or two citing it, and two, because I have enjoyed doing it myself. In the cut-and-paste world of computerized documentation, it’s addictively efficient. Gutenberg, the inventor of the printing press which allowed mass production of books and changed the world, would be proud. The responsibility for using such powerful efficiency does fall to the individual health provider to carefully review, edit, add and subtract documentation to ensure current accuracy. However, if done correctly, it allows careful preservation of a summary of what came before.

For this, I have some personal recommendations. First, actually DO the editing, don’t just cut, paste, and sign. Second, go back and refine the previous note for word choice and economy. Otherwise, you will create endless run-on documentation that is unprofessional in appearance and a burden for your colleagues to wade through later. From a billing perspective, it facilitates and supports that you have actually reviewed the patient’s previous history rather than just asking them what’s going on today. I find that cutting and pasting the old plan prompts me to consider everything I was trying to accomplish after the last visit and promotes holding the patient accountable for getting all of their previous orders accomplished. If something was not followed up on by the patient despite my recommendation, then this definitely gets documented in the current note. And then, of course, I ask them to “try, try again.”

I find nothing inherently wrong in this process and my patients get the benefits of an accurate portrayal and review of their conditions with appropriate follow up evaluation and managent. So cut, paste, edit, and save your evenings for yourself, rather than dictating entirely new notes that regurgitate the same old information. Work smart, while still working hard.

About the author

John Lynn

John Lynn

John Lynn is the Founder of the HealthcareScene.com, a network of leading Healthcare IT resources. The flagship blog, Healthcare IT Today, contains over 13,000 articles with over half of the articles written by John. These EMR and Healthcare IT related articles have been viewed over 20 million times.

John manages Healthcare IT Central, the leading career Health IT job board. He also organizes the first of its kind conference and community focused on healthcare marketing, Healthcare and IT Marketing Conference, and a healthcare IT conference, EXPO.health, focused on practical healthcare IT innovation. John is an advisor to multiple healthcare IT companies. John is highly involved in social media, and in addition to his blogs can be found on Twitter: @techguy.

13 Comments

  • Your last sentence reminded me of one of my college professor who continually admonished us to Work smarter, not harder! He was certainly not against hard work (hours and hours of it, sometimes), but he wanted to encourage individual problem solving and initiative rather than an automatic, mindless reaction when faced with an unknown variable. The other quote I remember from his class was, The difference is, I believe it can be done. That one always annoyed me (my mental comeback was I believe too: I just don’t know how!), but he was often right: the solution would sometimes be right there for me to find, if only I’d really looked for it.

    All that’s to commend your great words on the cut-paste controversy. I find it disheratening that so many want to disable this feature completely rather than find a way to utilize it effectively. Obviously sloppy cut and paste is prone to pitfalls: we’ve all received generic emails that needed just a bit more tweaking before they were sent out. But to make doctors type out pages of notes from scratch time and again, rather than utilize what’s already in the system, defies the very logic EHRs are built on. Just in my work as a content producer, I can’t imagine life without Ctrl+C. I sometimes copy words that I even think I could have typed as easily, simply to ensure accuracy. Surely doctors want and need the same convenience.

    So thanks for the rational analysis, Dr. West. I think it’s very sound advice.

  • I have one doc who started doing this back in the 80s and it really worked well for him. He specializes in internal medicine. At the end of his work day, he would prepare many of his notes for tomorrow. His patients had little change, and having the note prepared him in advance to laser-focus on specific problems. The appointment software would print the “future” visit note and he had something to jot on. (This provided billing with a very usable worksheet, too.) His actual update of the note would be very minimal. It worked well for him for 25+ years.

  • Robbing healthcare employees of the ability to cut and paste (particularly in situations such as this), is essentially robbing them of productivity, which is what EMR is supposed to increase in the first place. While errors are always a big fear, cutting and pasting is a pretty standard technique that we recommend to our clients, frankly. If it disappeared, there would be a lot of upset users.

    Carl

  • Offline I told John I didn’t think Dr. West had this right. John didn’t agree with me … so I should explain my thinking.

    I am opposed to cut and paste because I think it is too ad hoc, doesn’t help standardize treatment plans, or take advantage of what an EHR ought to provide the clinician as a decision and execution support engine.

    Option that docs ought to have is a clinician developed/approved template or macro that populates the document in the EHR with info in the system and prompts for standard language options which might change.

    Cut and paste to me is not far enough toward obtaining standardized inputs and improving the specialists advantage gained from the EHR.

    I’m adverse to cut and paste … because there are other options which are more to the advantage of the practitioners delivery of quality health care outcomes.

  • I can see your point, Don B, and agree that EHRs should provide many tools for physicians to accurately update patient records. However, I don’t think the fact that cut and paste is not the ideal tool for all uses means it has no use at all. After all, clincians aren’t the only ones who can abuse cut & paste. Think about the ethical issues involved were I to copy this entire post into my blog and post it as my own: I’d wound my credibility as a writer, violate the trust of my readers, and I’d have stolen John’s work. English instructors deal with plagiarism all the time due to copy and paste. But copy and paste is also a very useful tool for writers who want to quickly assemble lots of information for their work. I use it all the time.

    I recognize that there are different consequences if copy and paste is used inappropriately in an EHR as opposed to a blog. But I think the question remains: does the ability to misuse a tool mean it should be banned?

  • Thanks Michelle … I really do agree with you and John … I just think that incorporating a practitioner’s treatment protocol template serves to standardize clinical processes and quickly documents the work.

    I wonder how much push back from hospital administrators (or carriers) about cut and pasting the private template is all about … “our purist administration who were in charge of ensuring the highest quality, authentic notes for each patient on each day. In their correctness, they noted that sometimes these notes would be put into patient charts without those small changes that would, in fact, take place from day to day, thus resulting in erroneous documentation.”

    … or a way to create work for a practitioner to miss documenting and not getting reimbursed for providing?

  • Excellent, thought-provoking post from Dr. West.

    I have a background in publishing. Copy-paste functionality has made me look fast and efficient. It’s also made me look like a fool! Still, all in all, I’ll continue using it; it’s worth the risk.

  • Don B,
    Basically it just seems like you’re advocating a more advanced copy and paste. Not that the principles of copy and paste should be done away with.

    Michelle,
    You could copy my blog anytime. Just make sure you link back;-)

    Katherine,
    Well said!

  • Just wanted to thank all of you for your thoughts and comments. It’s makes me appreciate the blogging process all the more. I’ll be posting over at emrandehr.com from now on, John’s other blog site. Come stop in there from time to time!

  • I appreciate the cut and paste process in EMR-however, I have also discovered in my own EMR that there has been a chronic use and with some critical errors the errors have carried over and over again. I have needed to submit and resubmit multiple requests for correction.
    In a handwritten/or dictated MR, I have noticed over the years many less mistakes.
    Furthermore, I have also noted there are instructions reported to be given (by template) but never reached my ears.
    It is not the machine or process, it comes down to ethics, professionalism, and accountability.

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