Jan 8 Most doctors copy and paste old,
potentially out-of-date information into patients' electronic
records, according to a U.S. study looking at a shortcut that
some experts fear could lead to miscommunication and medical
"The electronic medical record was meant to make the process
of documentation easier, but I think it's perpetuated copying,"
said lead author Daryl Thornton, assistant professor at Case
Western Reserve University School of Medicine.
Electronic health records have been touted as having the
potential to transform patient data from indecipherable
scribbles into easy-to-read, searchable standardized documents
that could be shared among hospital staffers and a patient's
various other health care providers.
Many electronic record keeping systems allow text to be
copied and pasted from previous notes and other documents, a
shortcut that could help time-crunched doctors but that could
also cause mistakes to be passed along or medical records to
become indecipherable, critics argue.
To see how much information in patient records came from
copying, Thornton's team, in a study published in Critical Care
Medicine, examined 2,068 electronic patient progress reports
created by 62 residents and 11 attending physicians in the
intensive care unit of a Cleveland, Ohio hospital.
Progress notes are typically shared among doctors, nurses
and other hospital staff and are meant to document the
progression of a patient's tests and treatments.
Using plagiarism-detection software, the researchers
analyzed five months' worth of progress notes for 135 patients.
They found that 82 percent of residents' notes and 74
percent of attending physicians' notes included 20 percent or
more copied and pasted material from the patients' records.
Thornton and his colleagues did not examine what motivated
physicians and residents to copy and paste, or whether the
shortcut affected patient care.
But in one case, a patient left the ICU and was readmitted a
couple of days later. The patient's medical record included so
much copied and pasted information that the new team of doctors
wasn't able to decipher the original diagnosis. In the end, the
team called the physicians who originally diagnosed the patient.
Experts suggested that copying signifies a shift in how
doctors use notes, away from being a means of communication
among fellow healthcare providers and toward being a barrage of
data to document billing.
"What tends to get missing is the narrative - what's the
patient's story?" said Michael Barr, senior vice president in
the Division of Medical Practice, Professionalism and Quality at
the American College of Physicians. Barr was not involved in the
(Reporting from New York by Trevor Stokes at Reuters Health;
editing by Elaine Lies)