Restricted use of copy and paste in electronic health records potentially improves healthcare quality

Abstract

The copy-and-paste feature is commonly used for clinical documentation, and a policy is needed to reduce overdocumentation. We aimed to determine if the restricted use of copy and paste by doctors could improve inpatient healthcare quality. Clinical documentation in an inpatient dataset compiled from 2016 to 2018 was used. Copied-and-pasted text was detected in word templates using natural language programming with a threshold of 70%. The prevalence of copying and pasting after the policy introduction was accessed by segmented regression for trend analysis. The rate of readmission for the same disease within 14 days was assessed to evaluate inpatient healthcare quality, and the completion of discharge summary notes within 3 days was assessed to determine the timeliness of note completion. The relationships between these factors were used cross-correlation to detect lag effect. Poisson regression was performed to identify the relative effect of the copy and paste restriction policy on the 14-day readmission rate or the discharge note completion rate within 3 days. The prevalence of copying and pasting initially decreased, then increased, and then flatly decreased. The cross-correlation results showed a significant correlation between the prevalence of copied-and-pasted text and the 14-day readmission rate ( P < .001) and a relative risk of 1.105 ( P < .005), with a one-month lag. The discharge note completion rate initially decreased and not affected long term after restriction policy. Appropriate policies to restrict the use of copying and pasting can lead to improvements in inpatient healthcare quality. Prospective research with cost analysis is needed.

Artificial intelligence: revolutionizing cardiology with large language models

“… 140–143 Even though repeating mentions may indicate importance of a finding, duplicating content from previous clinical notes may be used as a shortcut to write clinical notes and result in the generation of clinical notes with redundant text. In current clinical practice, it has already been shown that duplication of clinical note content hinders 144 , 145 clinicians in their day-to-day process when determining the current vs. out-of-date state of patients and may introduce errors that potentially lead to safety issues. 146 Therefore, assessing text redundancy 147 and understanding the effect of note redundancy on developed NLP models are important, as text redundancy can have an impact on model performance.…”

Copy-Pasting in Patients’ Electronic Medical Records (EMRs): Use Judiciously and With Caution

“…This can be done quickly and easily using the copypasting function, ensuring that all relevant information is accurately and securely transferred. Multiple definitions describe copy-pasting, such as copying matching phrases of more than four words or 20 characters between two documents, or a note containing 20% copied text from another document will be considered copying, or 40 identical consecutive words between two documents will be defined as a copy event [8,[11][12][13][14].…”

“…According to a recent study, physicians typically spend 44% of their time on the computer, 26% on clinical documentation, and 18% typing on computers. This significant amount of time could be better spent providing direct patient care [ 13 ]. "Cut-and-paste" refers to cutting text from one location and pasting it into another during manuscript editing or re-writing.…”

“…Additionally, it is crucial to ensure that the copied content is appropriately attributed to its source. To meet timeline targets, physicians often trust and rely on the copy-pasting function, which is used by around 35.7% of physicians [ 13 , 15 ]. This function offers several advantages, such as improved efficiency in capturing data, consistency, completeness, and communication.…”

“…Additionally, it can help to improve accuracy and reduce errors in data entry, resulting in more reliable and up-to-date patient records [ 14 , 16 ]. However, a mistake in copy-pasting is reported to contribute to over 36% of errors [ 13 ] and can have severe consequences for patient safety. It can introduce new inaccuracies, propagate inaccurate or outdated information, create discordant notes, and lead to note bloat, which can obscure important clinical information.…”