Using the copy and paste function in EHRs presents significant safety concerns, according to a National Institute of Standards and Technology (NIST) report released last month.
For the report, NIST partnered with the ECRI Institute and the U.S. Army Medical Research and Materiel Command to conduct an in-depth analysis of how providers use the copy and paste function in EHRs, as well as providers' perceptions of whether the function could cause errors that could potentially affect patient safety. Researchers between July 2016 and August 2016 interviewed nurses and physicians who used the military's AHLTA EHR application.
The researchers found that although EHRs' "copy and paste functionality is intended to allow medical practitioners to easily and efficiently reuse information in patient EHRs without having to retype the information, ... in practice, current implementation of this functionality has introduced overwhelming and unintended safety-related issues into the clinical environment."
According to the researchers, the clinicians involved in the study cited several accuracy concerns with copied and pasted data, such as:
The researchers found that when clinicians are copying and pasting in EHRs, they have an "unconstrained ability to extract a large amount of information" from patients' records. This "can present users with convoluted and/or irrelevant information impairing situation awareness" and cause users to "miss important pieces of information," the researchers found.
In addition, the researchers found that when clinicians use the copy and paste function in EHRs, they sometimes "forget to properly review and edit all of the information they have copied and pasted," which can result in users copying and pasting incorrect information. The researchers added that EHRs do not provide users "with system features that promote efficient editing."
To improve the copy and paste function's "safety-related usability," the researchers recommended that EHR systems should:
According to Health Data Management, the researchers also included specific changes EHR developers should make to the copy and paste function for when users are transferring data between different departments or different patients' EHRs, as well as when providers are copying and pasting information related to:
Overall, the researchers in their specific recommendations reiterated that EHR systems should allow users to view clear chains of custody for copied and pasted information. The researchers also recommended that EHR systems should:
For vital signs, the researchers recommended that EHR systems should indicate how vital signs are measured and include timestamps for when they are measured, as well as for when:
A successful EHR system requires budget, resources, and planning—not only before it goes live, but after as well.
In fact, the process of implementing, deploying, maintaining, and optimizing an EHR system is similar to that of raising a child—each stage of the process requiring a unique subset of people to ensure its success. Learn more about the seven stages of the EHR life cycle in this infographic.
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