Electronic health records no doubt have many benefits such as ease of access, retrieval, sharing and medical records review among others. However, there are risks associated with them as many ongoing studies show. The greatest concern with EHRs is that they allow caregivers to easily copy and paste data from other parts of the chart. This results in the creation of a complex, ambiguous record that beats the very purpose of electronic documentation and puts the patients at risk.
In a recent study, researchers at the University of California San Francisco studied thousands of progress notes written by around 500 clinicians over 8 months in UCSF Medical Center’s inpatient Epic EHR. The researchers found that more than 80% of the notes were copied or imported from elsewhere and only a small minority were manually entered. This study is significant compared to other studies on copy and paste that have been limited in their ability to quantify just where and when EHR text originated. A recent software update to Epic allowed the research team to study the medical charts with “character-level granularity.” This means that the EHR can now identify whether the character was freshly typed, imported, or copied.
- 23,630 inpatient progress notes written by 460 caregivers – direct care hospitalists, medical students and residents – were analyzed.
- The study found that 46% of notes were copied and 36% were imported. Only 18% of the text was entered manually.
- 51% of Residents copied, and only 12% of them entered text manually.
- 16.2% of medical students entered manually while 49% copied.
- Among hospitalists, 47.9% copied whereas 14% opted for manual entry.
- Hospitalists wrote the shortest notes compared with residents and medical students.
The study results give serious food for thought. The obvious question that comes to mind is how clinicians can resort to such practices that put their patients at risk. Progress notes are expected to provide clear, updated information regarding the patient’s condition and the clinician’s thought process. The practice of copy and paste is highly risky because it increases the risk of including inaccurate, outdated, unnecessary information that can result in clinical errors.
The study team noted that research such as this can surely help EHR vendors understand the problematic areas and persuade them to design EHR that would make copied and imported information readily visible to clinicians as they are writing a note, but does not ultimately store that information in the note. Apart from EHR vendors, hospitals can also take constructive steps to improve documentation and make it streamlined.
Medical record retrieval companies and medical record review companies are also keen observers in this regard, hoping for a foolproof EHR system that can make the review of medical records much simpler. There is no doubt that with concerted effort such a system can be developed that will help meet all the objectives of EHR implementation.