Copying common in electronic medical records: study

REUTERS - Most doctors copy and paste old, potentially out-of-date information into patients' electronic records, according to a U.S. study looking at a shortcut that some experts fear could lead to miscommunication and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 Daryl Thornton, assistant professor at Case Western Reserve University School of Medicine.

Electronic health records have been touted as having the potential to transform patient data from indecipherable scribbles into easy-to-read, searchable standardized documents that could be shared among hospital staffers and a patient's various other health care providers.

Many electronic record keeping 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, in a study published in Critical Care Medicine, examined 2,068 electronic patient progress reports created by 62 residents and 11 attending physicians in the intensive care unit of a Cleveland, Ohio hospital.

Progress notes are typically shared among doctors, nurses and other hospital staff and are meant to document the progression of a patient's tests and treatments.

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.

Thornton and his colleagues did not examine what motivated physicians and residents to copy and paste, or whether the shortcut affected patient care.

But 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 that the new team of doctors wasn't able to decipher the original diagnosis. In the end, the team called the physicians who originally diagnosed the patient.

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 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 study. SOURCE: bit.ly/UKgOcP

(Reporting from New York by Trevor Stokes at Reuters Health; editing by Elaine Lies)