Electronic health records (EHRs) are meant to store the latest healthcare data, but much of the information is copied or pasted, which decreases accuracy and leads to clinical error. In a study, published in JAMA Internal Medicine, researchers from the University of California, San Francisco evaluated how data are documented with EHRs.
Many medical professionals have become accustomed to the “copy and paste” technique of EHR documentation. Researchers were able to use an updated EHR tool to differentiate between manually entered, copied and imported data to reveal the exact statistics on how data is documented in patient EHRs.
Evaluating inpatient progress notes within the Epic EHR system at the University of California San Francisco Medical Center, researchers used the software update to differentiate rates of manually entered data, imported data and copied data that had been pasted from a previous note. The study covered 23,630 notes taken by 460 residents, medical students and direct care hospitalists from January 10, 2016, to August 31, 2016.
Results showed only 18 percent of the data was manually entered, 46 percent was copied and 36 percent was imported. Residents copied 51.4 percent of data and manually entered 11.8 percent of data. Medical students manually entered 16.2 percent of data and copied 49 percent of data. Direct care hospitalists copied 47.9 percent of data, manually entered 14.1 percent of data and wrote the shortest notes.
“Future analysis will examine how copied and imported text is used to fulfill the various functions of a note, such as billing or clinical history recall,” concluded Michael D. Wang, MD, first author on the study, and colleagues. “This finding 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. For example, copied text used as a hospital course record to facilitate the creation of a discharge summary may represent an opportunity for the EHR to provide an alternative space for discharge information. Alternately, copied text that represents a belief that more text leads to higher billing suggests an opportunity for educating clinicians in how notes are coded.”