Between "Hangovers," Bradley Cooper starred in a largely forgettable melodrama called "The Words." The main character was an aspiring writer whose career first skyrockets and then implodes when he plagiarizes an entire novel from a dusty manuscript found buried in an old briefcase bought at an antique store. As art, "The Words" is destined for the on-demand scrap heap, but it may yet be redeemed as a cautionary tale for anyone who creates electronic health records.
While EHRs have many advantages that can improve health care delivery, including easy access and portability, the same technology that affords these advantages can also promote careless practices that may call into question the accuracy of the entire record and make it difficult, if not impossible, for health care providers to defend themselves in court. Among the most troublesome EHR misuses we see in litigation is the inappropriate use of copy and paste functions, whereby a health care provider "plagiarizes" his/her own or a colleague’s prior documentation.
In medical negligence claims, the accuracy of the patient’s medical record and the credibility of the health care providers are often both at issue, and many times the two go hand in hand. Lawyers representing injured patients love to point out errors in the medical record, whether or not the error caused any patient harm, because – the argument goes – if the medical provider was careless in record-keeping, then chances are he/she was also careless in the treatment at issue. So too, if the jury is provided with facts that differ from the medical record, suspicion arises. Thus, an innocent but preoccupied provider is accused of lying or of trying to cover up a treatment error. To avoid these insinuations, clinicians must put time and effort, as well as original thought, into medical record documentation.
Our experience in reviewing medical records for litigation suggests that a surprising number of practitioners routinely copy and paste information from a prior entry in the EHR. The excuses we have heard for this run the gamut from unfamiliarity with the electronic system to lack of time and, ironically, the need to ensure accurate documentation. Similarly, in "The Words," when Bradley Cooper’s character starts copying another author’s manuscript – word for word – onto his laptop, he tells himself that he is doing it simply for inspiration. Excuses aside, this kind of rote replication is seductively easy but fraught with danger, particularly if the EHR later comes under scrutiny.
When data from a prior note in the EHR are copied, little thought or focus is given to context or clarity, and the cobbled-together entry is frequently disorganized and unclear. Worse yet, such copying can result in entering outdated or inaccurate information into the patient’s chart. Even simple errors of this kind can be very damaging. Imagine trying to convince a jury that you are a careful and caring practitioner when it has been pointed out to them that, in your records, your patient’s blood pressure was exactly the same every time she was in your office over the last 5 years. Or that despite the fact that she was experiencing a precipitous, unexplained weight loss, you continued to describe her as morbidly obese. Or that even though her husband died 3 years ago, your records show her "accompanied by spouse" at every visit.
Sometimes EHR plagiarism goes right to the heart of the negligence claim. Where the claim is inappropriate discharge of a patient who died a few days after leaving the hospital, the defense must show that the patient’s condition improved and that troubling symptoms seen on admission responded appropriately to treatment. This effort is hampered by documentation prepared many days or weeks into a hospitalization that copies symptoms and physical findings that are no longer present. Inaccurate information in the EHR can also confuse other medical providers, and the time necessary to reconcile inconsistent information may delay treatment. Likewise, if inaccurate information is relied on for treatment decisions, the results can be disastrous.
It is often argued in litigation that if something doesn’t appear in the medical record it didn’t happen. A corollary to this dubious "rule" is that once bad information is documented in a medical record, it will be redocumented over and over and over again. Predictably, the more times the erroneous data are repeated in the EHR, the more "reliable" it becomes. This problem has been around a long time, but EHR plagiarism has made it worse.
The medical record is the most important evidence in any medical negligence case. While it is true that only a small fraction of medical records will ever see the inside of a courtroom, you should always document assuming the chart in front of you could end up there. This requires time, original thought, accuracy, and completeness. Copying and pasting the electronic medical record, while superficially efficient, is the enemy of these goals, and could leave you – like Bradley Cooper in "The Words" – wondering what happened to your promising career.