Copy-and-Past Standard Practice in EHRs, JAMA Study Shows

 

A new study from the Journal of the American Medical Association, researchers at University of California San Francisco took a look at thousands of progress notes, written by nearly 500 clinicians over eight months in UCSF Medical Center's inpatient Epic EHR.

They found that only a small minority of them were manually entered – but more than 80 percent of the notes were imported or copied from elsewhere.

Other studies on copy-and-paste have been limited in their ability to quantify just where and when EHR text originated. But a recent software update to Epic allowed the UCSF team to examine the charts with "character-level granularity," researchers said.

"The EHR now identifies the provenance of every character that is present in a signed note – that is, whether the character was typed fresh ('manually entered'), pulled from another source such as a medication list ('imported'), or pasted from a previous note or elsewhere ('copied')," according to the JAMA report. "Clinicians can opt to see this information, which is hidden by default but is logged in the EHR for every note written since the upgrade."

By examining the proportion of manually entered, imported and copied characters in the notes, UCSF researchers were able to learn some revealing things about documentation practices – and the people doing the documenting.

The team analyzed 23,630 inpatient progress notes written by 460 caregivers who were either direct care hospitalists, residents and medical students.

For the study as a whole, the UCSF researchers found that 46 percent of notes were copied and 36 percent were imported. Just 18 percent of the text was entered manually.

Only 12 percent of Residents entered text manually while 51 percent copied. For medical students, more 16.2 percent entered manually and 49 percent copied while 14 percent of hospitalists opted for manual entry versus 47.9 percent who copied.

Meanwhile, hospitalists wrote the shortest notes (5006 total characters), compared with residents (6720) and medical students (7053).

"The traditional goal of progress notes is to provide a concise, up-to-date reflection of the patient’s condition and the clinician’s thought process," said UCSF researchers. "However, copying or importing text increases the risk of including outdated, inaccurate, or unnecessary information, which can undermine the utility of notes and lead to a clinical error."

(Source: Mike Miliard; Health Care IT News [5/31/2017])