Friday, July 7, 2017

The problem of “copy and paste” in electronic records

As opposed to text that is copied and pasted or imported from another part of the electronic record, the average amount of manually entered information in a progress note is

a. 18%
b. 29%
c. 43%
d. 55%
e. 70 %

A study of 23,630 internal medicine progress notes written by 460 different hospitalists, residents, and medical students found that a mean of only 18% of the text was created by hand with 46% copied and pasted from previous note or somewhere else and 36% imported from another part of the record such as a medication list.

The analysis, done at the University of California San Francisco*, was possible because the Epic electronic medical record used there can provide the provenance of every character entered in a progress note.

Medical students had the highest percentage of manually entered text and wrote longest notes—averaging 7053 characters, but even the shortest notes, by hospitalists, averaged 5006 characters. For reference, this post contains 1189 characters.

Manual entry comprised 11.8% of resident notes with 51.4% of the remaining information copied and pasted and 36.8% imported.

Think about it. For all groups, less than one-fifth of every progress note they wrote was original material. For resident notes, it was closer to 10%.

The authors cautioned that their study was limited to a single service at a single institution, but I suspect the results would be fairly similar in many if not most hospitals.

*Location of the study corrected on 7/7/17.


Giada said...

as a patient I object to my records containing false info because of copy and paste. Sure, there is a ton of crap about my thyroid being normal (it isn't) but I don't care about that all that much because the enlargement is benign and essentially irrelevant. But don't copy and paste that I do not have a heart murmur. I have a huge murmur, reflecting a serious heart cond for which I am having open heart surgery next month. copy and paste all you want, but please don't paste stuff that is wrong and potentially dangerous. Either listen to my heart or leave it out. And if docs don't have time to listen to my heart, reconsider everything!! Thanks!!!

Joel Selanikio said...

Followup study: percentage of copy/pasted text that is fraudulent (e.g. physical exam findings documented as normal when that aspect of the exam wasn't done.)

Anonymous said...

Thank you for this. Vexing that such an important patient care (and probably educational) issue, one that has been known for quite some time, hasn't been addressed more aggressively.

It's UCSF, not the General. UCSF uses Epic. The General, a UCSF affiliate, uses a bunch of different EHRs (largely non-interoperable, of course), but not Epic.

Jayne said...

What is the benefit of essentially duplicating work that was already done? The likelihood for repeating an error is high and I am pretty sure every attorney on the planet would tell you to stop doing it. If they can access the record for the data you are typing, can't they access the data you are copying? Seems like work time wasted - no wonder wait times are so long and appointments take forever to schedule.

Skeptical Scalpel said...

Giada, I share your frustration. I hate reading those damn notes with their perpetuated mistakes.

Joel, that would be a great study. I hope someone does it. see another example of fraud in my response to Jayne below.

Anon, thank you for the correction. I have made the change.

Jayne, I agree it's a medicolegal nightmare. The mere act of copying and pasting even if the info is correct may undermine the credibility of the one writing the note. And pasting in a 12-point review of systems every day for a patient on a ventilator is clearly fraudulent.

Anonymous said...

Thank you for posting this. It is a serious issue that undermines the integrity of the profession, and hinders efficient communication. As teaching surgeons, my partners and I stress to our residents that the note is a place to communicate the author's own thoughts, and will not even allow importing of labs or radiology results (though we encourage free texting one's interpretation of those results). This is usually met with resistance.

The other issue is that, unlike a global post-op period, the internal medicine physicians are reimbursed based on the number of systems addressed in each note, so there is a financial incentive to "pad" the note.

Not so humorously, one of the egregious examples I've seen was copied and pasted every day for over a week (by the infectious disease doctors - plural). It began "Patient is a 78-year-old pregnant female…" No one bothered to correct it. Shameful.

Ms. Hot Flash said...

I wspe ially enjoy the notes about the patient being on a vent when in gact they are breathing room air.

lp said...

For those nonmedical people who don't know, the reason this is done is to increase the amount of money that can be billed for the encounter. If the insurance companies didn't keep cutting reimbursement, and would provide a reasonable fee for service, this would not be done. I'm not justifying it, but there is plenty of blame to go around. If there was a flat fee for every patient visit regardless of the documentation, this issue would go away. (I bet the notes for Kaiser docs are shorter.)

Emily said...

Skeptical, when you saw mistakes in a patient's record, do you have the right (obligation?) to correct it.

Anonymous said...

Quite obviously, the purpose of "duplicating" all that work is for billing purposes. I think it is self-evident that much of the point of expensive EHR systems generally is for "charge capture." It absolutely facilitates widespread fraud, and fraud that reimburses well. It is shameful.

Carlos Abril said...

I agree. Everything is made for billing, but it is our fault to keep doing this. It is really difficult to find a really good progress note, with a real and a good medical plan. Everything full of "copy and paste" and templates!! Patients with appendectomies have CT reports where you can see "the appendix is normal" or you can read the same OR note for 100 lap chole and so forth. And something more we even read the notes?

Carlos Abril said...
This comment has been removed by a blog administrator.
orthodoc said...

A more salient point: how much of the note is actually of use to anyone caring for the patient? Epic is particularly awful in this regard, but when I get a referral and review notes, the useful content is 1-2 lines out of a 4 page note. This is what happens when you mandate that doctors become stenographers.

Skeptical Scalpel said...

Anon, I love "Patient is a 78-year-old pregnant female…"

Ms. Hot, or how about "Pt is alert and oriented X3" when he is sedated and paralyzed on a vent?

Emily, yes, I tried to correct the record.

No question some of the copy and paste is done to pad the note for billing purposes.

Carlos, your comment was repeated by the system somehow. I deleted one of the copies. I too wonder if anyone really reads the notes.

Orthodoc, I agree that 95% of most notes is useless. Sadly, what is lacking is usually a coherent assessment and plan.

Anonymous said...

For years, I have taken to placing Assessment/Plan at the very beginning of any note. I don't deny that plenty of auto-populated information makes it into some of my notes (most especially on consult notes, where including labs, imaging reports, etc impacts billing), but the relevant information to other physicians is immediately available. It is frustrating that plenty of information that any physician reading a note would skip right by impacts reimbursement.

Skeptical Scalpel said...

Anon, it is a shame that the progress note, once a useful tool for communicating with other doctors, is now mainly used to justify a bill.

Glen said...

I would like the EMR to begin with a narrative from PCP or admitting physician covering the general history of the patient, and the indication for admission (or treatment). A concise narrative gives more information than 20 tables and graphs, and is much faster to read and assimilate.

"Mrs. Patient is a 45 year old married mother of three, living with her husband and youngest child. At age 16 she was in an auto collision that left her with a shattered pelvis. She reports worsening belly pain over the past 2 years. CT shows 5 masses adjacent to pelvic surgical hardware. Admit for laparoscopic assessment/repair of adhesions.

That is more helpful than 20 pages of cut and past EMR

Skeptical Scalpel said...

Glen, good point. I would also like to see a brief summary of any important events that took place since the last progress note. I would also like to see a concise and meaningful description of what the clinician is thinking, what she plans to do, and why she plans to do it.

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