Thielke SM (GRECC, VA Puget Sound Health Care System), Hammond KW
(COE-Seattle), Weir CR
(GRECC, Salt Lake City VA Medical Center), Embi PJ
(University of Cincinnati), Hedeen AN
(COE-Seattle), Efthimiadis EN
(Information School, University of Washington)
Copying and pasting (CP) has been observed frequently in the electronic medical record, and is reported to affect record quality and clinical care. We sought to characterize the range of CPRS users' perspectives on CP across clinical environments and user groups.
We conducted 14 focus groups with practitioners, nurses, and administrators at four geographically distinct VA locations across the US. Following a semi-structured approach, groups were asked about perceptions of EMR-based documentation using open-ended questioning, with CP issues solicited if they did not arise spontaneously. Interview transcripts were analyzed using an iterative, grounded-theory approach, and themes around CP were identified and categorized.
CP was a significant concern for users across all participant groups, with most comments arising spontaneously without need for prompting. It was perceived to be “frequently used,” “overused,” “over-relied on,” and “too easy to perform.” Greatest usage was thought to occur among practitioners, particularly in outpatient settings, and the greatest concern was expressed by administrators. Some users claimed to spot CP easily, while others said it was hard to identify. From a reader’s perspective, the most pervasive theme was that CP generated inaccurate information, specifically by destroying the chronology of a patient's history and the care provided. CP was perceived to reduce the quality of clinical notes, making them lengthy and uninformative, and increasing the burden of record review. CP was described as undermining the validity and trustworthiness of clinical notes. Legal complications were mentioned, including fraud, and two instances of patient harm were described. People who used CP said that it was essential to allow them to complete their work efficiently. Suggestions were made to distinctively label copied text in CPRS.
Providers, nurses and administrators from settings across the US felt that CP within CPRS was pervasive, had concerns about its impact to workflow and care, and yet found it to be a useful feature of CPRS documentation.
The quality of clinical care in the VA hinges on an accurate, trustworthy computerized patient record. System improvements around copying and pasting might improve quality, and should be developed accounting for various user perspectives.