Control+C, Control+V — Out of Control?

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).


8 responses to "Control+C, Control+V — Out of Control?"
  • December 7, 2012
    Michael Gross

    I know Faith Fitzgerald. I review charts sometimes and look at office notes and every note looks the same due to copy/paste. so you never really know whats going on fron 1 date to the next office visit, very disturbing trying to review for quality

  • December 7, 2012
    Marilou Terpenning

    The ongoing continued documentation of erroneous medical information has long preceded electronic medical records. Any physician can, for example, share the difficulty of substantiating the diagnosis of sickle cell trait or disease by reviewing the 10 volumes of paper medical records that take hours to come up from medical records, when a patient labeled as having sickle trait/ disease presents in pain. Mental control C/ control V has long existed before personal computers, let alone electronic health records. So doctors aren’t perfect and less so when in a hurry. And who is not in a hurry today to document, review all data now at our fingertips, make a rapid decision, document the decision, place diagnostic/ therapeutic orders personally, send electronic prescriptions, then enter billing and finally transmit the communication. There are more patients and more to come and all in direct patent care are working hard. So what is good about EHR is the incredible ability to have converted our previously plus/ minus accurately documented history (kept in separate silos) into data bites that permit abstraction and population study. We have legible records and can provide patient’s summaries of their after visit instructions. Clinicians have the ability to instantly obtain advanced decision support to help with rapid decision making. We have the ability to quickly see combinations of labs and data in time oriented flowsheets so trends can be rapidly seen.
    Any new technology in its early phases will have problems. Giving up the good as clinicians adjust to the challenges will move medical care backwards. Criticizing EHR for a long held clinician practice of pulling info from their own or prior notes of others when trying to tell a patient’s story pulls us backwards.
    Clinicians are awkwardly moving into EHR. More clinician input into template development to develop rapid accurate documentation is needed. Doctors are taught to tell the story in med school. Learning EHR is, for many, the equivalent to bring expected to learn Japanese with 8 hours training and then to tell the story well and to type it not dictate it.
    Leading change is difficult. Laughing at or criticizing changes is easy. We are on a learning curve with feedback expected to only make the process better. At the end of the day, once experience grows, skill grows. We at the beginning of this transition. Mature use of EHR awaits us.
    Kudos to all who have committed to the process. Patient care will improve and patient engagement will begin.

  • December 8, 2012
    Carol Greenlee

    To comment on the comments about moving the “core data” into every note as indicator of doing more “work” and upcoding….this just emphasizes the need to move that core data to position of a “reference document” that is pulled from as needed (ie that patient with a sore throat has strep, do they have PNC allergy noted in the core data set?, pull that into note by referring to the core data) and not have this “regurgitated” data as the centerfold of the note ….what a crazy idea to begin with …the idea that detailing those items was the largest measure of the “work” done during the appointment or beyond the appointment. Even those who supported this early on have done a mea culpa on this idea….all it does is make it easy for someone to do a checklist type of audit. Having these items bulk up the progress note actually deters from care and from our handoffs and makes it hard to find the meat of what is going on with the paitent and any thought process for the encounter….like “looking for Elmo”…and the cookie cutter notes do the same.
    I care for patients with chronic disease so their follow up appointment needs to truly follow up on the plans and treatment changes from the last appointment and that is where the cut and paste is useful, to add those changes to my new progress note so I can f/u on them since my EMR vender saw no need to have a way to carry treatment forward (such an unimportant item !)

  • December 8, 2012
    Randall Oates, M.D.

    The fashion with which information technology is being interjected into the doctor-patient relationship almost always is forcing docs to choose between one or more monsters:

    Doctrollus – turns doctors into distracted data entry trolls.

    Enslavus – robs doctors of their free time.

    Hemsucus – sucks the life blood out of medical practices.

    Rubishus – turns medical records into mostly rubbish.

    Alchemus – tricks doctors into thinking narrative free text is gold.

    Cephinsandus – tricks doctors into thinking it will all go away because it is so wasteful of the physicians time and attention.

    Fortunately, there are solutions emerging that don’t create monsters, but obsolete EHR systems and engrained physician habits are often hard to overcome.

  • December 8, 2012
    alan lazaroff, m.d.

    I think that the fundamental problem is the requirement to fill medical documents with clinically irrelevant “information” for billing purposes. Physicians cut and paste this stuff because it has nothing to do with taking care of the patient. Talk about a time waster! This strategy predates the EMR, but the EMR allows doctors to “play the game” more effectively. That is precisely how EMR’s were sold and what they were built for. A bad system with a bad set of rules produces bad outcomes. The solution lies in reform of the payment system.

  • December 9, 2012
    Richard Wasserman, MD, PhD

    As Dr. Terpenning correctly pointed out, EMR is not the cause of bad data in medical records. It is all about the integrity of the physician entering the data. I can’t be the only one who has seen a PE body parts list with a straight line through the normal column when the HPI didn’t justify a 12 system PE or a dictation transcription that is mostly, sometimes exclusively, memorized boilerplate that the physician vomited into the dictaphone at the end of a day when 20 or 30 or more patients had been seen. As soon as longhand was replaced by dictation, forms and checklists, it became easier for physicians to be dishonest in small ways, recording a PE finding when no exam was done. EMR certainly facilitates such dishonesty but is not the cause. At the same time, even the sickest patient has a lot of negative or normal ROS and PE findings; starting documentation with a standard normal and individualizing the record by documenting exceptions is efficient and appropriate.

    To Dr. Greenlee’s point, my EMR templates incorporate, in a well demarcated space, previous data so that I can see it easily as I speak to the patient and create the note. I don’t use it to justify a higher visit code.

    The relationship between quality of care and medical records is uncertain but there are activities that are associated with improved patient outcomes; controller medications for persistent asthma, hemoglobin A1C monitoring for diabetes, etc. Auditing records is one way to improve care by providing systematic feedback to physicians. Auditing an illegible scribble is impossible.

    If physicians spent less time complaining and being cute and more time adapting their systems to the way they think and practice everyone would be better off.

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  • January 21, 2013
    Bruce Jackson

    The new HIPPA makes it easier for pats to see their doctors’ notes and THAT will be interesting.

    I saw a specialist a few years ago for three or four visits on a minor problem. I was curious and ordered my patient record since they had gone to Epic and were electronic. His first note declared that I was 20 years older than I was and I had a condition different from what I was in for (he got his patients confused). What was the most interesting was that the notes for the ensuing visits still had me as 20 years older and with the same condition (which according to his notes was improving by the way).

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