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Dr. David Juurlink posted this on twitter recently:

Boy, do I agree. But I use it daily in my practice because it’s an extremely helpful tool…when used correctly. So, how should it be used?

Before I get to that, let’s beat it to the ground. A review of the literature is overwhelming with the amount of published papers regarding copy/forward.

Let’s take a look at some top points (with some extension to EHR’s in general):

Problems:

Copy/forward is prevalent.

According to this study, over 50% of the words in notes are copy/forwarded from previous notes. OVER HALF!

Most physicians don’t see Copy/Forward as a problem.

81% physicians do not see copy/forward as having a negative impact according to this study.

That study was in 2008, and sentiments have likely changed. But while a new poll would likely show a greater awareness of negative impacts, most physicians likely fail to acknowledge the negative impacts of THEIR OWN use of copy / paste.

Increased Errors

Average of 1.01 error per copied note. “Copying another clinician’s note and making changes had the highest risk of error.” Not a surprise.

Poor communication of priorities and the narrative story

Problem Lists Never Change. The #1 problem at the top of an A&P should be the most important problem for that day. But this is lost with Copy/Forward as the problem list rarely changes after its first iteration: “This causes notes to not only fail to reflect the orderly progression of thought and action but also rarely provides clear documentation of that day’s events.”

Narrative Function is Lost. “Because charts have become capacious warehouses of disorganized, irrelevant, or erroneous data, the story of the patient and the patient’s illness is no longer easy to read.” This is of great concern as “narratives form the basis of clinical decision making.”

Fraudulent billing

Straight from the OIG: “When doctors… copy-paste information but fail to update it or ensure accuracy, inaccurate information may enter the patient’s medical record and inappropriate charges may be billed... Furthermore, inappropriate copy-pasting could facilitate attempts to inflate claims and duplicate or create fraudulent claims.”

Wasted time confirming or finding data

Although EHR’s have increased the availability of documentation, it decreases the confidence of the data in that documentation. Physicians then spend extra time CONFIRMING that information. These problems were described as “information overload” and “information scatter” in this study: “Duplicated information wastes clinician time on tedious fact searching and confirmation, generates inaccurate documentation, obfuscates the original source of text, and ultimately leads to medical errors. Information scatter… leads to wasted time retrieving data, or worse, missed information because clinicians lack time to adequately search the EMR.”

Less critical thinking

I wish I’d found this paper for my issue on the objective section. “…Automated data entry affected their ability to identify pertinent findings. With manual data entry, the very act of handwriting data caused the author to consider it, even if for a moment. …Automation led to a loss of this reflective process, causing concern that they had missed pertinent findings. Several subjects even reported specific instances in which they had missed important findings documented IN THEIR NOTES.”

So, why do we copy/paste?

Decreased burnout

Yup, you read that correctly. According to this study, “The only variable independently associated with decreased reporting of burnout was a clinician’s use of copy-paste.” This is likely due to the perceived improvement of efficiency.

Improved comprehensiveness

As said in this paper, appropriate copy-paste can improve the comprehensiveness of notes and help providers avoid the invisible error of omission.

Billing

U.S. notes are 4x longer than other countries.

Why? I love this statement here: “Using copy/paste to more efficiently author notes that meet the real OR PERCEIVED requirements of…billing…” Billing is the #1 excuse people give for the length of their notes. BUT, it’s often the PERCEIVD requirements rather than the TRUE requirements of billing. (This is the BASIS of my next video course for attendings: clarifying a lot of the misconceptions of billing so we can write shorter, more accurate yet complete notes.)

How do I use copy/forward?

Many papers suggested urging physicians to review their notes for accuracy. That’s true, but what is not recognized enough is that most physicians think they’re READING their notes when in actuality they’re SKIMMING them…and their SKIMMING isn’t sensitive enough to identify errors.

So, I format my note to make it skim-proof:

I do copy/forward the active problem list. But I move the top problem of THAT day to the top. I also RESOLVE and REMOVE problems from the problem list anytime I can.

Under individual problems, the section is effectively divided into two parts:

1. Evergreen information

2. A short, updated, bulleted plan

Not every problem needs both.

Evergreen: Information that is accurate regardless of copy/forward. I am intentional to never include relative terms such as “tomorrow,” “yesterday,” etc. in this section. This section may include pertinent dates of procedures, baseline information, etc. which are easy to forget, and I feel is important to carry forward daily for myself and/or others.

I do copy/forward my plan but it’s in the format of a short, bulleted list with short sentences. Because it’s in this format, I KNOW I MUST edit this every day. This improves my efficiency and accuracy.

An example might look like:

The non-bulleted section is my “evergreen” section. If the patient remains in the hospital for other reasons, in subsequent notes I may:

• Resolve and delete “acute blood loss anemia”

• Move “Acute GI bleed” from the #1 spot

• Specify an “around date” for GI follow up and move the comment about follow up to the evergreen section (to remind myself and others upon discharge).

• My bulleted plan includes ONLY things that I’m updating THAT day. So, in subsequent notes the section under “Acute GI bleed” may lose its bulleted list completely and become entirely evergreen. I might add language such as “initial reason for hospitalization” and “continue PPI BID.”

Admission H&P’s often have clinical reasoning / discussion under problems. I keep this above my bulleted plan in a manner similar to the evergreen section. I then DELETE that discussion in my next note to keep my note concise. Initial discussions from the initial H&P are a TOP source of note bloat and make it seem a patient is much more complex / unstable then they truly are on THAT day.

My favorite use of copy/forward is staying organized with complex workups. My most common example is encephalopathy of unclear etiology. Above my bulleted listed plan, I’ll include:

Positive:
Negative:
Pending:

This requires daily updating. It not only keeps ME organized but communicates what has or hasn’t been done to others - especially those taking over my patient. In cases like this, I see TOO often that results are overlooked, or THE BASICS are never done because it was assumed to have been done but the volume over information was overwhelming. This becomes even more paramount if you have multiple patients with similar presentations.

What can we do?

No, we can’t disable the copy/forward function.

Multiple papers came to the same conclusion:

• Hospitals need to monitor, assess, and give feedback on copy/forward usage.

• And give frequent education to clinicians. “Review your notes for accuracy” doesn’t work. Use the points from this newsletter to provide better education. I recommend using screenshots of copy/forwarded inaccuracies to drive home the point. This study, with a single lecture given on the problems with EHR documentation and a suggested best-practice template, saw that notes became “concise while adequately complete” and had “approximately 25% fewer lines and were signed on average 1.3 hours earlier in the day.”

Finally, as one paper stated: “We must realign [trainees] incentives so that documentation has meaning - for the patient and those providing the care.” (THIS is my mission…via this newsletter, social media, and my video courses, to first and foremost show how good documentation helps the author AND their patients.)

Happy Thanksgiving! And don’t forget to use my BLACK FRIDAY DISCOUNT BF2023 at checkout to save 15% off my Resident Guide to Clinical Documentation. Expires Wednesday 11/29.

That’s all for now. I hope that was helpful.

Please feel free to reach out and ask questions as they help inspire future issues!

Cheers,

Robert

When you’re ready, there are two ways I can help you:

Check out The Resident Guide to Clinical Documentation. The course that helps you:

• Cut note-writing time by >50%

• Prevent medical errors and lawsuits by using notes to stay organized

• Learn how to use copy/forward in a way that is both efficient yet safe.

• Become real-world ready by structuring your notes for billing

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