A 77-year-old woman was admitted to a teaching hospital with diarrhea and dehydration after completing her fifth cycle of chemotherapy for ovarian cancer. Her only relevant past medical history included a postoperative pulmonary embolus after hip surgery. This preceded her ovarian cancer diagnosis by several years, and she was treated with 6 months of warfarin with no subsequent events.

The patient was admitted and received intravenous fluids and an infectious evaluation of her stool. The final line of the intern's admitting note also stated that the patient would receive subcutaneous heparin for venous thromboembolism (VTE) prophylaxis, although this was never actually ordered. The patient's care was transferred to a different team the following day, and the accepting intern copied and pasted the plans of the admitting intern into the new note within the electronic health record (EHR). The same note was then copied and pasted on 4 consecutive hospital days and cosigned by the resident and attending, and the patient was ultimately discharged having never received the intended VTE prophylaxis—despite each day's note stating this as part of the plan.

Two days following discharge, the patient developed acute shortness of breath and hypoxia and returned to the hospital, where she was diagnosed with a pulmonary embolus. Only at this admission, and after careful review of the medication record from the previous hospitalization, was it realized that the patient never received any VTE prophylaxis.

by William Hersh, MD

The benefits of electronic health records (EHRs) are increasingly well-documented. A systematic review in 2006 found substantial evidence for three major benefits: increased adherence to guideline-based care, enhanced surveillance and monitoring, and decreased medication errors.(1) In the particular domain of this case, VTE, one study has shown substantial benefit for computerized decision support.(2)

However, the evidence is not all positive, as some studies have uncovered "unintended consequences" of EHRs and other health information technology.(3) In addition, there is conflicting evidence on the value of computerized physician order entry (CPOE), with some studies showing that it increases errors (4) and mortality (5), while others demonstrate its benefit.(6-9)

One concern that has been raised about the EHRs is the ease with which patient information can be "copied and pasted." When this is done for information that is different or has changed, it has the potential to introduce and/or propagate errors in the medical record. Indeed, this has been identified as a concern of EHR users (10) and has been shown to occur in 10%–20% of all charts.(11-13) One of these studies developed and validated an algorithm for detecting such copying.(12) A detailed instance of this problem was recently reported.(14)

Before delving into the issues raised by this case, we should note that copying information in patient charts is probably something that has been done since the development of the very first medical records. As with many record-related issues, this would be nearly impossible to quantify with paper records, due to information being difficult to process, let alone read. So we must remember that copying information in medical records is not necessarily new, although EHRs clearly make it much easier to do.

The safety issue raised by this case is not limited to EHRs: how to insure that information specified in the narrative medical record is translated into actual orders and implementation. Although this commentator has never seen it documented, it would be interesting to know how often the narrative plan of the medical record differs from actual orders implemented by the physician, whether on paper or electronically.

The solution to this problem, of course, should be based on the solution to all errors of omission in medicine: the use of clinical decision support to remind the physician to carry out things like VTE prophylaxis and other "corollary" orders that are not infrequently forgotten.(15) Indeed, stereotyped order sets are one area that has been shown to increase physician acceptance of and satisfaction with CPOE.(16)

Should errors like this lead us to prohibit copying and pasting? It depends on the information copied. There should probably be no prohibition against copying verified historical information, such as an illness or surgery from the past. But more recent information, especially that likely to change, such as a physical examination, should not be copied. Perhaps physicians should be freely allowed to "cite," with attribution, past medical history and other unchanging information. But we should be vigilant about not condoning copying and pasting of more recent information when erroneous reproduction may lead to patient harm. Likewise, we must be adamant that information not be copied and pasted to inflate the level of service that might lead to higher billing.

This case also demonstrates that physicians must be taught, as they have been since medical records were first developed, that it is their responsibility to carry out the plans documented in their records. In this modern era of EHRs, this point, plus the risk of copying and pasting, must be driven home in education and training to use EHRs. Attention must also be paid to using clinical decision support to reduce errors of omission.(17)

Take-Home Points

• Copying and pasting of patient information has probably been occurring since the beginning of recorded medical information.
• EHRs make copying and pasting very easy.
• When copying and pasting is done, the physician should be careful to attribute the source and to check that the information being pasted is not erroneous or out of date.
• The most effective means for insuring medical plans are carried out is through the use of clinical decision support tools, and such tools are made easier and more acceptable to use when orders are bundled in sets.

William Hersh, MD
Professor and Chair
Department of Medical Informatics & Clinical Epidemiology
Oregon Health & Science University

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