Copying Information in EHRs Common Among ICU Physicians
Copying
and pasting old, potentially out-of-date information into patients' electronic
health records (EHR) is common among physicians in the intensive care unit
(ICU), according to a Reuters Health article based
on a study that examined
2,068 electronic patient progress reports created by 62 residents and 11
attending physicians in a Cleveland hospital ICU.
Using plagiarism-detection software,
the researchers analyzed 5 months' worth of progress notes for 135 patients. They
found that 82% of residents' notes and 74% of attending physicians' notes
included 20% or more copied and pasted material from the patients' records.
In their report, published in Critical Care Medicine, the authors
did not examine what motivated physicians and residents to copy and paste, or
whether the shortcut affected patient care, says Reuters.
Nothing about a patient—length of stay, sex, age, race or ethnicity, what
brought them into the ICU or how severely ill they were—affected how often a
physician copied information into the medical record.
Although residents' notes more often included copied material, attending
physicians tended to copy more material between notes. They also tended to copy
more of their own assessments from other notes.
Experts suggested that copying information signifies a shift in how
physicians use notes—away from being a means of communication among fellow
health care providers and toward being a barrage of data to document billing,
the article says.