Study shows copying common in EHR notes
Electronic health records (EHRs) have long been touted as a transformative tool in medicine. The data can be shared easily between the patient and medical staff, medications can be automatically screened to ensure safety, and a doctor’s scribbles can be changed to easily read text. All of this good, however, is dependent upon the information in the EHR being accurate, reports the National Association of Healthcare Access Management.
Many EHR systems allow users to copy and paste information, and according to one study, this step can cause information to be incorrect or outdated. The study, done by a team at Case Western Reserve University School of Medicine, examined 2,068 progress reports for 135 patients in the ICU of a Cleveland hospital. The reports were created by 62 residents and 11 attending physicians, and they were monitored over five months using plagiarism detection software. (To access the study, published in “Critical Care Medicine,” go to http://bit.ly/Tp1f8j. To access the Reuters article about the study, go to http://reut.rs/UEz6KB.)
The team found that in 82% of the notes made by the residents and 74% of the notes made by attending physicians, 20% or more of the text was copied and pasted from preexisting text from the patient’s records. These reports are used by internal hospital staff to monitor patient progress, but text containing a significant amount of pasted information might not be helpful. In one case, doctors of a patient who was released and then readmitted to the ICU couldn’t understand the previous progress reports. The pasted notes gave no clues as to the original diagnosis, and the new doctors had to call the diagnosing physician.
This study could signal that doctors are using notes as more of a method to document billing then as a method to communicate with other healthcare staff.