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Hospitals Beware: EMR Copy And Paste Common

Posted on January 16, 2013 I Written By

Anne Zieger is veteran healthcare editor and analyst with 25 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

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out, courtesy of EHR Intelligence, there are reasons to be concerned when this much copying is going on, including outdated records, incorrect billing requests and worst of all, mistakes in documentation which could harm vulnerable ICU patients.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.

Are Doctors Creating Useful Charts In Your EMR, Or Phoning It In?

Posted on October 27, 2011 I Written By

Katherine Rourke is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.

Folks, tonight I hope to nudge everyone who reads this to realize that they’ve got a problem to solve. The problem: How you’ll get doctors interested in using that pretty EMR you bought. I mean fully use, not just do the minimum, to the point where your institution can do something with the data.

As readers know, data collection requirements are mounting as Meaningful Use requirements phase in.  And patients will get more chances to review that data over time.  You want the e-charts not only to provide a basis for good care, but also meet regulatory requirements, participate in health plan programs and even offer consumers a nice glimpse of reality through soon-to-emerge patient portals.

The thing is, here at HospitalEMRandEHR, we’re hearing increasing noise about doctors who, under tremendous stress, are essentially cutting  and pasting background info into templates.  This is a Bad Thing. Data paired with observations in text areas produces a meaningful package; data packaged with boilerplate language may translate into pages of almost worthless content.

You know, even if your doctors aren’t offering as much context on patients as they used to, the charting they do may be good enough to scrape by and get MU incentives paid to you.  The doctors may still provide enough information to convey the sense of what they did to others, and follow up too.

That being said, it just doesn’t make sense to accept the bare minimum when you’ve spent so much, and ultimately, hope to see clinical improvement as one of the payoffs from your EMR investment. So, bear in mind that you don’t just have to win over physicians to tolerating EMRs — you’d better be sure they’re willing to adapt to EMRs culturally, which means that they figure out how to produce value in an EMR-based record.

If you’re thinking “Hey, I’m not sure how to do that myself,” then figure it out, hopefully after having good talks with thought leaders on your medical staff. Create some standards for creating a rich EMR record and encourage physicians to support their colleagues in creating them.  After all, the last thing you want is to demand one more thing from your doctors if you’re not sure yourself what you want.