Most doctors copy and paste old, potentially out-of-date information into patients’ electronic records, according to a new study looking at a shortcut that some experts fear could lead to miscommunication and medical errors. “The electronic medical record was meant to make the process of documentation easier, but I think it’s perpetuated copying,” said lead author Dr. Daryl Thornton, assistant professor at Case Western Reserve University School of Medicine in Cleveland.
According to the report in Reuters Health, many electronic recordkeeping systems allow text to be copied and pasted from previous notes and other documents, a shortcut that could help time-crunched doctors but that could also cause mistakes to be passed along or medical records to become indecipherable, critics argue. To see how much information in patient records came from copying, Thornton’s team examined 2,068 electronic patient progress reports created by 62 residents and 11 attending physicians in the intensive care unit of a Cleveland hospital.
Using plagiarism-detection software, the researchers analyzed five months’ worth of progress notes for 135 patients. They found that 82 percent of residents’ notes and 74 percent of attending physicians’ notes included 20 percent or more copied and pasted material from the patients’ records. In one case a patient left the ICU and was readmitted a couple of days later. The patient’s medical record included so much copied and pasted information, the new team of doctors wasn’t able to decipher the original diagnosis. In the end, the new team called the physicians who originally diagnosed the patient.
Nothing about a patient – length of stay, gender, age, race or ethnicity, what brought them into the ICU or how severely ill they were – affected how often a physician copied information into the medical record. Although residents’ notes more often included copied material, attending physicians tended to copy more material between notes. They also tended to copy more of their own assessments from other notes.
Experts suggested that copying signifies a shift in how doctors use notes – away from being a means of communication among fellow healthcare providers and toward being a barrage of data to document billing. “What tends to get missing is the narrative – what’s the patient’s story?” said Dr. Michael Barr, senior vice president in the Division of Medical Practice, Professionalism and Quality at the American College of Physicians. Barr was not involved in the current study.