Medicine is rapidly changing with the advances in technology. Few will argue the benefits of having an EMR are great. However, there are also a number of increased risks. One major risk, happening at an alarming rate is “note bloat” caused by improper copy – paste within the clinical notes.
In a recent study performed by researchers at the University of California San Francisco, it was determined that a mere 18% of inpatient notes in EPIC were manually entered at UCSF Medical Center. This means that 80% of notes were copied or imported from somewhere else.
Copy – paste functionality is acceptable, but the provider MUST properly edit. There must be clear evidence as to what happened during the clinical encounter. It is essential the integrity of clinical documentation is held to the highest standards for both the safety of the patient and the institution.
JAMA Internal Medicine – published May 30, 2017
One benefit of the advances of technology in healthcare has been the implementation of the EHR. This has created a greater, more seamless flow of information between health professionals. However, it has also introduced unintended safety issues by allowing the use of ‘copy-paste’.
Clinical treatment plans are heavily determined by the provider’s clinical documentation integrity. If clinicians are abusing the ‘copy-paste’ functionality they are compromising the accuracy of the information. NIST began asking the difficult questions such as “In what ways, if at all, do participants (clinicians including physicians and nurses) believe the ‘copy and paste’ function in EHRs contributes to or helps prevent errors related to patient safety?”
NIST partnered with ECRI, U.S. Army Medical Research and Materiel Command’s, and Telemedicine and Advanced Technology Research Center to conduct a study on the impact of misusing ‘copy-paste’ functionality. To read the full article follow the link below.
NISTIR 8166 – published January 2017
In the past ten years or so there have been two significant transitions in medicine. First, the transition from paper records to Electronic Health Records. Second the transition from providers being paid based on the quality of care and patient outcomes rather than the number of patients seen or procedures performed- Quality vs. Quantity.
When Congress passed the HITECH Act in 2009 the intent was to encourage forward progress into the digital era in medicine. Today, nearly all U.S. based hospitals have made the transition to Electronic Medical Records. However, to say the transition has been successful, remains a debate. Physicians remain frustrated by the poor usability of the EHR systems. As many of my clients have stated it is easy to put information into a patients chart, but to find the information you need when you need it is next to impossible. With the increasing challenges in medicine, how are providers suppose to focus on the medicine?
As with any advancement, obstacles continue to emerge. These obstacles must be understood and addressed properly. An article recently published in The New England Journal of Medicine, the author address the need for interoperability and the need for standardization across all systems. EHR companies have a long way to go to provide both the patient and the providers all they need. We have made huge advancements, but what is our path forward?
New England Journal of Medicine – published 2017