Two experienced patient safety analysts from ECRI Institute Patient Safety Organization (PSO) performed this analysis. Events reported from 2013 to 2015 were de-identified and described for analysis. Data from adverse events and hazards were submitted by providers and provider organizations using the Agency for Healthcare Research and Quality (AHRQ) Common Formats and HIT Hazard Manager taxonomies. The Partnership also collected data under the protection of a patient safety organization (ECRI Institute PSO).
Based on these deliberations and drawing on the eight-part sociotechnical model, the workgroup developed recommendations and implementation strategies for the safe use of copy and paste. During this time the workgroup reviewed copy and paste events, discussed results from the systematic literature review, and solicited presentations from topic experts across different stakeholder groups. The Partnership’s multi-stakeholder workgroup convened in February 2015 and met monthly for six months. Although cognizant of the regulatory, legal, and compliance issues around reimbursement fraud, the workgroup intentionally focused on identifying clinical risks and possible interventions for safe copy and paste functionality to improve patient safety.ģ.1 Overview of The Partnership for Health IT Patient Safety workgroup process
FALSE INFORMATION DETECT COPY AND PASTE TEXT PROFESSIONAL
This workgroup was composed of a diverse group of stakeholders including vendors, providers, representatives from professional organizations, academicians, and safety experts. The Partnership collectively decided to establish single-topic workgroups addressing particular patient safety issues the first workgroup was established to address the practice of copy and paste. The Partnership for Health IT Patient Safety (The Partnership) was formed to gather data, conduct analysis, provide education, and disseminate recommended practices with the goal of enabling safer care using health information technology (IT). Office of the Inspector General found that only 24% of organizations had a copy and paste policy in place. Nevertheless, a recent report by the U.S. Additionally, copy and paste may enable reimbursement fraud, allowing users to easily attest to care they have not provided. Subsequently, professional organizations including the American Health Information Management Association, the Association of Medical Directors of Information Systems, and the Federation of State Medical Boards have formally addressed aspects of copy and paste use in position/guidance statements. In a large physician survey, 25% agreed that copy and paste makes progress notes more likely to lead to a mistake in patient care. However, copy and paste may also promote longer, poorly organized, and less accurate notes due to inclusion of redundant, outdated, or inconsistent information. Many clinicians use the copy and paste functionality provided by operating systems in electronic health records (EHRs) to improve usability by allowing providers to insert text with test results or exam information, maintain stable medication lists, and improve documentation efficiency, particularly when systems lack interoperability.
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