Think for a second about how much text you type by hand, rather than copy or import, into progress notes. Is it half? 25%?
Just 18% of progress notes were composed of manually entered text in a recent study of 23,630 notes written by 460 direct-care hospitalists, residents, and medical students on the general medicine service at the University of California, San Francisco (UCSF).
The rest of the text was either copy-pasted (46%) or imported from other parts of the electronic health record (EHR) such as templates or lab reports (36%), according to the study's results, published online in May and in the August JAMA Internal Medicine as a research letter. Differences in EHR record-keeping practices were negligible among the types of clinicians.
Lead author Michael D. Wang, MD, ACP Member, a hospitalist and clinical informatics fellow at the UCSF division of hospital medicine, recently spoke with ACP Hospitalist about the potential implications.
Q: What led you to study this issue?
A: It actually dates back to my medical school days, which was the first time I was exposed to an electronic health record clinically. I still remember, one of my family practice mentors mentioned that he had seen his physical exam copied over 10 times amongst different specialties over the next year or so from his clinic note. So that got me interested in how much we use copy and paste and whether or not it's affecting patient care.
Q: Were you surprised at how much was copied and pasted?
A: Anecdotally, and even from my own personal experience, the rates that we found for both the manual entry as well as the copy and pasting were consistent with what we expected.
Q: What concerns does this raise for you?
A: One thing that we've discussed internally is a concept we've been calling documentation validity. We define this as how much a physician provider can believe that the information contained in note text is both accurate and up to date. A major problem with poorly curated copy and paste is that the information is not always accurate or up to date, which makes it hard to then use that information to make future decisions.
One of the articles I cited [in the study] was a piece that found that in primary care diagnostic errors, copied text was found in about 7% of progress notes with the identified error. Copying and pasting was thought to contribute to the error in more than one-third of the errors. [“Types and origins of diagnostic errors in primary care settings” by Singh et al, JAMA Internal Medicine, 2013]. In that study, it was a small contributor to medical errors, but I suspect we copy and paste more than we did when that study was published.
Q: Why do you think there is so much copy-pasting and importing in notes?
A: I think a lot of it has to do with the fact that the note serves many purposes now. I think historically, the daily progress note was literally just a “What happened today” note. But nowadays, there's a billing component of the note, there's a clinical history component of the note, and unfortunately, the EHR doesn't take care of those other components in any kind of place outside of the note. The note has become a home to those other functions, and I think copying and pasting helps us be more efficient when the note is also serving those other functions. It certainly makes our day go by faster.
The clinical history is a particularly important function of the note these days, especially on the inpatient setting for medicine. The provider changes every week or so, and so for patients who have been in the hospital for a long time, it's really important to pass on to the next provider what has happened to that patient in the hospital. The progress note has become where we do that, basically, and that's where the copy and pasting allows us to maintain the patient's story without having to retype it in ourselves every single day.
Q: A new tool in your EHR allowed you to look into this. How does that work?
A: With our system, since you can keep track of what text is copied and pasted, anybody reading the note after you've finalized it can see what sections are copied and pasted. It's similar to “Track Changes” in Word. If the whole paragraph were copied, in some EHRs, that shows up as yellow or bold, and then the text that you then manually type will get registered as manually entered within that block of copied text. So that actually already resolves a lot of the issues with copy-and-pasted text for immediate clinical decision making, as far as a reader figuring out what is newly entered text versus not-as-accurate copied text.
Q: Looking ahead, do you think EHR design is going to solve this problem?
A: My hope is that EHR design will continue to evolve. We're seeing a lot of what we call “note bloat,” which is when you have a lot of copied text just gumming up the chart. I think then, even with the ability to tell what's copied and manually entered, as a patient develops hundreds and hundreds of notes, it becomes hard to really parse out the clinical story. As EHRs evolve and improve, they'll hopefully do a better job at the interface level of capturing the clinical history of the patient. Addressing the billing component is going to be more complex. I think a lot of that work will happen at the policy level, as far as how do you capture a physician's workload, because that's all derived out of documentation right now.
Q: What's the biggest takeaway of your study for hospitalists?
A: I think it's a matter of being aware of when you're copying something and making sure that you read through it carefully. It's a powerful timesaving tool, but it's also one that should be used cautiously.