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Sloppy Electronic Health Record Practices Harm Patients

As medical technology continues to advance, the way that health care providers keep records of the care they provide patients has also evolved. Many health care providers are switching to electronic health records, as they seem to offer several benefits over traditional paper medical records. Proponents of EHRs note that these records are superior in that they collect all a patient’s care provider notes in a centralized location for a more complete picture of a patient’s status. Many people can access the records at once and the chance of gaps in the information in the records is less. Additionally, the records are easier to read because people do not need to decipher handwriting. However, one major drawback that has developed in the use of EHRs is that health care workers are simply using the “copy and paste” feature to carry notes forward, so the notes do not accurately reflect the patient’s condition. Patients are suffering because health care workers are cutting corners.

Taking shortcuts

Research supports the idea that copying and pasting information in EHRs is a widespread practice. A study in the February 2013 issue of Critical Care Medicine looked at 2,000 progress notes from a hospital and found that 82 percent of the notes had 20 percent or more text copied from one day to another. An earlier study published in Journal of the American Medical Informatics Association found a copy and paste rate of 78 percent in the sign-out notes and 54 percent in progress notes that researchers looked at from internal medicine residents.

Health care providers use copy and paste to save time, but they often do not make sure that everything they are copying is true of the patient’s condition at the time they are copying. In some cases, it merely leads to confusion among the multiple care providers attending to a patient, such as when the notes report a patient is “day two post-operation” for several days’ worth of notes. However, sometimes confusion leads to tragedy – like when patients receive unnecessary and
harmful procedures that were already performed because the “copy and paste” notes continue to call for them each day.

Critics of copy and paste notes also argue that this technique disrupts the narrative flow of health records and makes accurate
diagnosis nearly impossible. As each day passes, notes get longer because of copy and pasting from previous days and errors can accumulate.

Possible solutions

The Department of Health and Human Services’ Office of Inspector General announced in October 2012 that it intends to begin reviewing EHR notes of patients with multiple notes by the same health care provider to monitor the level of copying and pasting. Some have suggested that one way to eliminate the practice is to turn off the copy and paste function in EHRs entirely. Others have proposed a radical reform of the way health care providers make patient notes, calling for a system where health care providers can edit notes collaboratively. EHRs would function in a similar manner to Wikipedia, the well-known open-source online encyclopedia.

Talk to an attorney

Most would agree that striving for efficiency in health care is a laudable goal. However, when shortcuts that health care workers take end up harming patients, they need to be held responsible. If you have been injured by a medical error, speak with a seasoned medical malpractice attorney who can help you recover an equitable settlement.