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Study: Clinicians Copy and Paste About Half of Text in EHR Progress Notes

June 1, 2017
by Heather Landi
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A University of California San Francisco Medical Center study found that about 80 percent of the text in a typical progress note is copied or imported by clinicians.

In the study, the results of which were recently published in JAMA Internal Medicine, the UCSF Medical Center researchers noted that electronic health records (EHRs) allow physicians writing progress notes to supplement traditional manual data entry with copied or imported text. “However, copying or importing text increases the risk of including outdated, inaccurate or unnecessary information, which can undermine the utility of notes and lead to a clinical error,” the study authors wrote.

To this point, the ECRI Institute has addressed the issue of copying and pasting health information (e.g., orders, notes, labels) as being widespread, often underreported, and has the potential to cause adverse patient safety events. The Partnership for Health IT Patient Safety, a multi-stakeholder collaborative convened by ECRI Institute, released recommendations on the safe use of copy and paste functionalities last year.

A report published earlier this year from the National Institute of Standards and Technology (NIST) described the findings from a usability study of the “copy and paste” functionality in electronic health records (EHRs). “’Copy and paste’ functionality is intended to allow medical practitioners to easily and efficiently reuse information in patient EHRs without having to retype the information. However, in practice, current implementation of this functionality has introduced overwhelming and unintended safety-related issues into the clinical environment,” the NIST report authors stated.

The results of that study aligned with the Partnership for Health IT Patient Safety recommendations on “copy and paste” functionality. In the NIST report, data overw​​​helmingly supported two of the Partnership's safe practice recommendations—making copy-and-paste materials easily identifiable and ensuring that the provenance of the material is readily available. The study indicated that clinical users could benefit greatly from training on when and how copy-and-paste is appropriate to use.

Analyzing 23,630 progress notes written by 460 clinicians, the UCSF Medical Center researchers found that in a typical note, 18 percent of the text was manually entered, 46 percent copied and 36 percent imported.

For the study, the researchers used an inpatient Epic EHR that distinguishes manual, imported and copied text in hospital progress notes with character-by-character granularity and analyzed inpatient progress notes written by direct care hospitalists, residents and medical students on a general medicine service over an eight-month period.

According to the study authors, after a software update, the Epic inpatient EHR identifies the provenance of every character that is present in a signed note—whether that character was typed fresh (manually entered), pulled in from another source such as a medication list (imported) or pasted from a previous note or elsewhere (copied). The researchers examined each note for the number and percentage of manually entered, imported and copied characters.

The study authors further noted that residents manually entered less (11 percent of the text) and copied more (51 percent of the text) than did medical students (16 percent of text manually entered and 49 percent copied) or direct care hospitalists (14 percent manually entered text and 48 percent copied).

The researchers concluded that less than one-fifth of note content was manually entered, a finding that was difficult to obtain with previous study methods.

“Future analysis will examine how copied and imported text is used to fulfill the various functions of a note, such as billing or clinical history recall. This finding could spur EHR design that makes copied and imported information readily visible to clinicians as they are writing a note, but, ultimately, does not store that information in the note,” the study authors wrote. “

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