Apart from the case record, no mechanism exists in medicine that brings its diverse elements together. Improving these clinical portraits and striving to enlarge their usefulness must be central goals of medicine, for the case records are the works that define its essence.
Dr. Stanley J. Reiser (The clinical record in medicine. Part 2: Reforming content and purpose. Ann Intern Med. 1991;114980-51991)
Those of you using Windows-based computer systems will recognize that Control+C and Control+V are keyboard shortcuts for copying and pasting. While most of us use these and other related functions of our computer systems routinely for non-medical communication, in the case of electronic health records are clinicians undermining the trust in our profession by inappropriately using the copy/paste features of EHRs? The most recent article I’ve seen on this subject is from Leora Horwitz in the New York Times Opinion pages last week, entitled, “A Shortcut to Wasted Time.” She relates the oft-cited example of an inpatient’s chart reflecting on several sequential days that the patient was on “Day 2” of antibiotics. That’s a relatively minor example of erroneous documentation of a timeline… but what else was copied/pasted in the note that is not as easily identified?
I recently started practicing in a private office (after-hours/weekends) and had to learn a new electronic health record system. After the first few visits, I noted that the final progress note produced by the system (which could not be viewed in total while actually working on the components of the documentation) included information that I had not personally entered or verified (e.g. family history, surgical history). The default process was for these past elements of the history to be brought forward into even the simplest of visits (e.g. sore throat, cough). It is this type of unnecessary documentation that is often used to support increased coding — which has come under scrutiny (see this blog post from early October). While insertion of previously documented and personally verified/updated information pertinent to a specific encounter is a reasonable use of the EHR copy/paste shortcut, “clinical plagiarism” — the meaningless, repetitive use of unverified, potentially incorrect or misleading, templated information that clutters important new information — is not appropriate and can potentially be dangerous. Clinicians need to look beyond the expedience of copy/paste and remember the critical importance of clear, clinical documentation that captures the patient’s narrative, the clinician’s assessment, and the plan for further evaluation/treatment.
In an Annals of Internal Medicine essay earlier this year (subscription required) entitled, “The Emperor’s New Clothes,” Dr. Faith T. Fitzgerald tells the story of a patient with documented history of Ehlers-Danlos Syndrome, which is characterized by extremely loose joints, hyperelastic skin, easy bruisability, and fragile blood vessels. The patient described by Dr. Fitzgerald had multiple joint surgeries, hospital admissions, and presented an infected joint. Every note in the EHR reflected a past diagnosis of Ehlers-Danlos syndrome. However, Dr. Fitzgerald being the extraordinary diagnostician that she is, determined that the patient did not in fact have any of the physical findings of this disorder and likely had another syndrome: Munchausen syndrome. She writes:
The EMR is a wonderful but dangerous tool. Its capacity for efficient redundancy or, more perniciously, overt and unedited cut-and-paste from previous notes, allows doctors — either pressed for time or uncertain of themselves (as even very good doctors continually are) — to simply replicate their previous notes or parrot the antecedent notes of another clinician. This poses an increasingly particular danger for medical students, who tend to believe that everybody else must know more than they do. Yet, it is a hazard not just for students, but for all of us.
Do you use the copy/paste features of your EHR? If so, what controls do you place on your personal use? Do you train staff to verify and not just duplicate prior elements of the history?
This post is the personal opinion of the author and does not necessarily reflect the official policy or position of the American College of Physicians (ACP).