News: JAMA study reveals massive amount of copy-paste in EHR progress notes

Any CDI specialist who’s gone through a transition from paper records to an electronic health record (EHR) system knows the new technology is far from perfect. In the latest finding, a study by the Journal of the American Medical Association (JAMA), published on May 30, found that more than 80% of the studied progress notes were the product of copy-paste.

Researchers at the University of California San Francisco (UCSF) looked at 23,630 progress notes, written by 460 clinicians over an eight-month period in the university medical center’s inpatient EHR, Healthcare IT News reported.

Previous studies of EHR use were limited by an inability to see the origins of the text in the record. Thanks to a new EHR tool, however, the researchers were able to track both the source of the text down to the character.

According to the findings, only 18% of the text inpatient records was entered manually. In contrast, 46% were copy-pasted and 36% were imported from elsewhere in the record.

The study also shed light on the copy-paste/importing culprits. Since UCSF Medical Center is a teaching facility, the researchers were able to breakdown the numbers even further to determine the habits of hospitalists, residents, and medical students.

The findings revealed that only 12% of residents entered the text manually. Medical students faired a little better with 16.2% entering information manually. Finally, hospitalists fell right in the middle with 14% entering text manually into the EHR.

“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,” wrote the 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 “However, copying or importing text increases the risk of including outdated, inaccurate, or unnecessary information, which can undermine the utility of notes and lead to a clinical error.”

In its 2013 Position Paper, ACDIS acknowledged that “copying and pasting of documentation has become a commonplace problem,” and while it “does not recommend that CDI specialists position themselves at the forefront of correcting copy/paste problems,” it does call on them to be vigilant and to “take note of copy/paste errors and bring them to the attention of an EHR or other professional.”

Editor’s note: To read the entire report from JAMA, click here.