The humble copy paste function within EDR programs has been the source of much discussion and debate within the healthcare industry. For doctors who are already stretched for time during the typical workday, the copy paste workflow can be a very convenient shortcut. Medical professionals tend to see patients with similar problems during the week and documenting the same information several times manually (typing or dictation) is time-consuming. On the other hand, federal oversight agencies have been very concerned that this workaround can lead to fraudulent usage or EDR ‘up coding’ among providers.
Proponents of copy paste argue that this function is one of the ways by which users of electronic systems save time when compared to paper files. But an excessive reliance by doctors on copy paste can have alarming consequences. First and foremost, a doctor who generally uses copy paste may not scrutinize the clinical notes carefully to ensure that the documentation corresponds to actual treatment received. This can easily lead to a situation where the patient is prescribed the wrong medication or treatment based on incorrect documentation.
Besides compromising the patient’s medical history record, the appearance of clinical notes which are exactly the same for multiple patients can raise flags during an audit. Even if the provider did not intend to commit fraud, the audit team may recommend that federal incentives be recouped. In addition, such usage patterns can leave the practice open to lawsuits if health outcomes are adversely affected. Most EDR software products contain auditing functions that cannot be disabled and the digital trail can be used to show that the doctor was negligent or inattentive.
Nevertheless it cannot be denied that the copy paste function is very useful for overworked medical staff. Rather than eliminating the function entirely, practices should consider raising awareness among employees regarding long-term consequences. Proper training can go a long way in educating users regarding the pitfalls of using copy paste, so that staff use it sparingly and where appropriate. EDR vendors can also include templates for clinical notes based on patient/office visit type so that users can quickly fill in information without resorting to copy-paste. Even if default templates are not included, users should be able to generate them on the fly to suit their own needs.
Dovetail EDR is a cloud-based system which is designed with input from practicing dentists. The application was developed after extensive analysis of existing workflows in dental practices to ensure that users do not have to resort to workarounds or shortcuts.