Electronic medical records have been touted as a salve for many common scourges involving documentation within the healthcare system, including medical errors and miscommunication among providers.
Yet the majority of physicians copy and paste old and potentially outdated information into EMRs, according to a new study.
“The electronic medical record was meant to make the process of documentation easier, but I think it’s perpetuated copying,” said the study’s lead author Dr. Daryl Thornton, assistant professor at Case Western Reserve University School of Medicine in Cleveland.
While most EMR systems allow patient data and information to be copied and pasted from notes and other documents, thereby saving time for on-the-run physicians, the ability to do so can lead to inaccurate information and, potentially, dangerous errors in patient care.
To find out how prevalent copying is among physicians, researchers from Case Western examined more than 2,000 electronic records that had been created by approximately 70 physicians working in a Cleveland-area intensive care unit.
The vast majority of physicians engaged in copying patient information, the researchers discovered. Approximately 82 percent of the residents’ note and 74 percent of the attending physicians’ notes included at least 20 percent copied-and-pasted information.
While the exact effect on quality-and-safety outcomes remains unclear, the researchers discovered that in the case of one patient who was readmitted the medical record contained such a glut of copied information as to deem it indecipherable. In this case, the new team was forced to call the physician who made the original diagnosis for clarification.
In a larger context, what goes missing in this emerging trend of mass copying is the patient’s story, according to researchers. The focus instead is driven more by a doctor’s need to capture billing data. This can leave out valuable pieces of information.
“If your communication isn’t accurate, timely, complete and factual, then you really could be transmitting bad information forward that then creates this tumbling effect,” said Ann Gaffey, president of Healthcare Risk and Safety Strategies, in a report.