A key benefit from using electronic health records is that it improves care coordination, given that information can be shared easily between care providers. But a new study published in JAMA shows that EHRs contain mostly copy-and-paste data, which may put patient safety at risk.
Researchers at University of California San Francisco examined 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.
"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 "However, copying or importing text increases the risk of including outdated, inaccurate, or unnecessary information, which can undermine the utility of notes and lead to a clinical error."
For this study, UCSF researchers analysed 23,630 inpatient progress notes written by 460 caregivers who were either direct care hospitalists, residents and medical students. It was found that 46 percent of notes were copied and 36 percent were imported. Only 18 percent of the text was entered manually.
Only 12 percent of Residents entered text manually while 51 percent copied. For medical students, 16.2 percent entered manually and 49 percent copied while 14 percent of hospitalists opted for manual entry versus 47.9 percent who copied.
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')," the researchers explained. "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."
In the UCSF study, researchers found that hospitalists wrote the shortest notes (5006 total characters), compared with residents (6720) and medical students (7053).
The research team hopes that their findings could "spur EHR design that makes copied and imported information readily visible to clinicians as they are writing a note but, ultimately, does not store that information in the note."
Source: Healthcare IT News
Image Credit: Pixabay
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EHR, patient safety, copy-and-paste data, EHR design
a new study published in JAMA shows that EHRs contain mostly copy-and-paste data, which may put patient safety at risk.
