EMR templates are both a curse and a blessing. On the one hand, they systematize clinical data in a way that makes it far easier to share, aggregate and study trends. But the down side, and it’s a big one, is that EMR templates tempt clinicians to save time by cutting and pasting old data from patient’s record into current visit notes. The following study gives us a look at just how easily copy-and-paste can become a (bad) habit for clinicians in a hospital.
To study template use, an assistant professor at Case Western Reserve University School of Medicine brought together a group of colleagues to examine EMR-based progress reports. The group looked at 2,068 electronic progress reports created by 62 residents and 11 attending physicians, all of whom were working in the intensive care unit of a Cleveland hospital.
To determine how common cut-and-paste content was in the notes, the researchers reviewed notes for 135 patients over a five-month period using plagiarism-detection software, iHealthBeat reports. The results? They found that 82 percent of progress notes created by residents contained 20 percent or more of copied and pasted material from patient records. Meanwhile, 74 percent of progress notes created by attending physicians contained 20 percent or more of material cut-and-pasted from patient EMR records.
I’m not writing this to beat up on doctors, who certainly have their hands full simply coping with the new systems. Cut-and-paste is a natural instinct when you’ve spent your life doing so successfully in Word docs and spreadsheets. But as the iHealthBeat piece points out, courtesy of EHR Intelligence, there are reasons to be concerned when this much copying is going on, including outdated records, incorrect billing requests and worst of all, mistakes in documentation which could harm vulnerable ICU patients.
Seems that cutting and pasting within EMR documentation is a problem that’s not going to go away on its own.