Do healthcare workers copy and paste into electronic health records? You bet. Apparently, it's a fairly widespread practice.
However, providers might be increasing the risk to patients by simply entering repetitive and inaccurate EHR clinical data into physician notes, according to a recent study published in JAMA Internal Medicine.
Specifically, researchers from the California San Francisco Medical Center used the feedback from more than 20,000 notes written by 460 clinicians, and used a recent Epic EHR update to determine which method providers used to enter EHR clinical data. In so doing, they were able to determine how information was entered into the system — manually, imported or copied over.
Likewise, researchers reviewed inpatient progress notes by direct care hospitals, residents and medical students from more than eight months from Jan. 10, 2016, to Aug. 31, 2016.
As such, researchers noted that as little as 10 percent of the texts were "manually entered."
"46 percent was copied and 36 percent was imported," EHR Intelligence reported. "Demographically, residents manually entered only 11.8 percent of the text and copied 51 percent of the text as opposed to medical students, who manually entered 16.2 percent of the text and copied 49 percent."
Direct care hospitals manually entered 14 percent of the text and copied 47 percent, and they also provided the shortest notes of all groups. Medical students wrote the longest notes. The impact at the point of care might be that copying or importing text into a record may lead to shortcuts that could erode the level of information with the patient record.
"Copying or importing text increases the risk of including outdated, inaccurate or unnecessary information, which can undermine the utility of notes and lead to a clinical error," the researchers said in their report. "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. Electronic health records allow physicians writing these notes to supplement traditional manual data entry with copied or imported text."
Copied information may be repetitive, redundant or even nonspecific or missing certain elements.
Less than one-fifth of notes were manually entered. The researchers said that additional studies will continue in the future "on how copied and imported text fulfills different functions of a note, such as billing or clinical history recall," EHR Intelligence notes.
In the future, EHR users might view copied information but omit any repetitive data from final physician notes while entering data into another patient EHR without saving the information and risking redundancy.
"This finding could spur EHR design that makes copied and imported information readily visible to clinicians as they are writing a note," researchers said.
