In a perfect world, a hospitalist starting her shift would find a succinct summary of her patient's condition and plan of care upon opening the electronic health record (EHR). But in reality, she often has to wade through pages of repetitive, unedited notes that have been carried over from past entries—lots of information, but not necessarily the right information in the right place at the right time.
“There is a lot of carrying forward of the exact same plan of care and the same impression of what is going on,” said J. Daryl Thornton, MD, ACP Member, a specialist in pulmonary and critical care medicine at MetroHealth Medical Center and an assistant professor at Case Western Reserve University School of Medicine, both in Cleveland.
“If a person came in with shortness of breath, for example, consecutive progress notes might say that the physician was ordering a chest X-ray over and over again even though the X-ray had been performed and the patient had been placed on antibiotics. The notes just hadn't been updated,” he said.
Dr. Thornton and his colleagues found many similar examples in a January Critical Care Medicine study conducted in the medical intensive care unit of MetroHealth. The study concluded that 74% of attending physicians' EHR notes and 82% of residents' notes contained at least 20% of the information copied from previous notes.
“That leads to confusion,” said Dr. Thornton, “because it's hard to figure out what was done, when it was done, what the physician's thought process was, what the next step is going to be.”
Copying forward gives a command to bring forward parts of, or the entire, previous note into a new progress note, and to update certain structured information, such as blood pressure, labs and medications. Copying and pasting involves copying text verbatim from any note and pasting it into any another location.
Both practices can help physicians be more efficient by spending less time on data entry and more time on direct patient care, experts said. However, problems arise when physicians fail to review and update what they've copied to ensure that it is accurate and pertinent to the patient's current situation.
Editing is key
The ability to copy forward information from a patient's previous visit is useful for providing context, said ACP Fellow Michael Zaroukian, MD, PhD, vice president and chief medical information officer of Sparrow Health System, as well as chair of ACP's medical informatics committee.
“Before I see a patient, I frequently look at their last history of present illness or what their last exam showed and pull it into the note if relevant,” said Dr. Zaroukian, who is also a professor of medicine and former chief medical information officer at Michigan State University in East Lansing. “Even though I assess the patient's condition today, I do so in the context of my previously recorded history, examination, assessment and plan, reusing the information that is relevant and unchanged. I update what is new or different and include the patient in the discussion of important changes, saying ‘Here's what we saw last time.’”
“Copying and pasting poses a higher risk of error than copying forward,” he added. “That's because ‘copy forward’ automatically updates structured information, such as vital signs and test results, to the latest values, while ‘copy and paste’ takes information from another location and pastes it verbatim into the note.”
Dr. Zaroukian emphasized that in either case, physicians have a professional responsibility to update the information in the current note as needed to ensure that it is accurate and up to date. “Some of the most important and valid concerns about use of copy-and-paste comes from examples in which physicians have copied and pasted information without reviewing it for accuracy or updating the information as necessary,” he said.
Such actions can lead to blunders like stating that a patient is the same age as he was three years ago, when the note was originally written, said Peter Basch, MD, FACP, an internist and medical director for ambulatory EHR and health information technology policy at MedStar Physician Partners in Washington, D.C.
“I am sure people are abusing the copy forward, either by copying forward a prior finding and not editing it as appropriate, or by copying forward sections of an exam which may be correct, but either weren't examined or were not pertinent to the visit or progress note,” he said.
It is natural, however, for much of the phrasing physicians use in their notes to be similar or identical to past notes, such as when they are describing the same patient's prior exam or another patient with the same condition, said Dr. Basch. “That's just evidence that the author attended medical school and learned how to express findings in a standardized format,” he said.
“It isn't the similarity or even sameness of verbiage we should be worried about, but whether or not what was documented was appropriate and correct,” Dr. Basch continued.
Avoiding ‘note bloat’
The convenience of copying and pasting in EHRs can be a double-edged sword for physicians, experts said. Retrieving, reading and moving around data is much easier with EHRs than with paper, but that same convenience can lead to bloated notes that don't necessarily convey much new information and make it hard to find the most pertinent facts.
“True patient assessments and treatment plans may be missed and adverse patient outcomes may result,” noted Dr. Thornton and colleagues in the Critical Care Medicine study. “Copying may also lead to less independent thought, thereby hampering the development of alternative diagnoses and treatments. This is of particular concern in training the next generation of doctors.”
Part of the problem may stem from physicians' frustrations with viewing lab, imaging, test results, and even prior progress notes at the same time the current progress note is being written in the electronic record, said Dr. Thornton. Many physicians are used to turning back and forth between sections in a paper record to retrieve specific data in real time but find it awkward or disruptive to switch between these windows and screens as they write their note on the computer.
“It's much easier to say, ‘I'm not going to look that up, I'm just going to bring the information forward,’” he said.
EHRs also enable “data dumping,” Dr. Thornton said, as opposed to selecting the most relevant data for the current note. It's easy to tell the computer to include the results of the patient's last 20 X-rays, for example, but it creates a note that is “incredibly cumbersome and difficult to read,” he said.
The current payment system, which values volume over quality, also encourages physicians to over-document, said Dr. Zaroukian.
“Physicians have to navigate the tension between the need for documentation for billing purposes and improving quality of care,” he said. “More documentation equals higher reimbursement under the current payment system, and that drives a greater urge to copy forward information that might not be necessary to the quality of patient care.”
Similar to cars in the 1930s, EHRs are a major technological advancement that's still a work in progress, said Joseph H. Schneider, MD, clinical assistant professor at the University of Texas Southwestern and chief medical information officer and medical director of clinical informatics at Baylor Health Care System in Dallas. Many hospitals are developing and testing ways to prevent inappropriate copying and pasting, and to alleviate physicians' frustrations with the new technology.
For example, automatically updating notes with current vital signs and test results is one way that EHRs have been improved to prevent errors, Dr. Schneider said. Baylor is also considering inserting the name of the original author into each note, so that physicians can see whether or not the most recent note had been updated from the previous note, he said. The author's name would stay the same if the note was copied over without revisions but change if another physician reviewed and edited its content.
Other ideas include drawing attention to content that has not been updated by putting it in a different color, he said. For example, if a discharge note said that a central line was still in place, that portion of the note would be highlighted for the physician to review because in most cases it is unlikely that a patient would be discharged with a central line.
“As EHRs get more sophisticated there will be more and more subtle controls or guardrails that will keep you from falling into traps,” said Dr. Schneider.
Those kinds of improvements make much more sense than implementing plagiarism software or eliminating copy forward, which some have suggested as means of preventing errors associated with copying notes, said Dr. Basch. Instead, hospitals should focus on more training for physicians in using the copy forward function appropriately and about their responsibility to verify the accuracy of the note.
“It's easier to make a longer note than a shorter one because it's easy for the EHR to pull forward buckets of information,” he said. “Technology can pre-populate certain fields in the record and that's useful, but the physician still needs to take a little more time to make sure that what they're pulling forward and editing is correct and appropriate for the purposes of the visit or note.”
Ultimately, hospitals should be focusing on the fundamental issue of what the EHR progress note really needs to convey, said Dr. Basch.
“The progress note should contain concise, clear, legible, meaningful information that is accurate and complete,” he said. “In addition to providing a record of care, it should provide a roadmap for the next provider of care.”