A recent editorial in the American Journal of Medicine highlights the dangers of cutting and pasting data in an electronic health record.
The editorial was written by Ronald Adelman, MD, medical director of the Irving Wright Center of Aging and co-chief of the Division of Geriatrics Medicine and Gerontology at The New York-Presbyterian Hospital, and Eugenia L. Siegler, MD, medical director of the Geriatrics Inpatient Service at the Weill Cornell Campus of New York Presbyterian Hospital.
Adelman and Siegler contend that cutting and pasting data from one source to another reduces credibility of the recorded findings. This makes sense. For the next clinician reading the chart or record, it may be unclear if they understand that the information they see is not first hand or even second hand. It may be a matter of patient safety. Or it may not matter, but there should be some notation that the information has a primary source.
I agree that cutting and pasting also clouds clinical thinking and disrupts narrative flow and function of the chart. It's too easy to resort to cutting and pasting - this is the era of automation - and putting less relevant information into the chart. I agree that the functionality should be "shut off" and vendors should create a way to block the ability to cut and paste from records other than the EHR.
That said, there is a place for cutting and pasting - for instance when the factual information such as patient name and address would be too inefficient not to have that information pre-populated in the EHR. Cutting and pasting's function is to eliminate repetitive keystrokes. It shouldn't be used for such critical things as medical diagnosis in a previous admission. There should not be any shortcuts in medical documentation.
Vendors may want to be proactive in this area. Providers may want to collaborate with their vendors to tweak the functionality to make it an asset, and not a liability for the EHR and for patient care. Time to successfully achieve meaningful use is pretty short. So adjusting some of the functionality is something vendors should deal with in a swift, collaborative manner.
