Time to Cut 'Copy and Paste' from Electronic Medical Records?

History-Taking, Plagiarism, and Epistemology

Joseph M. Pierre, MD

Disclosures

July 07, 2017

A Game of 'Digital Telephone'

The biggest cost is that information in the EMR is often treated as gospel, whereas like so much online information these days, it should be consumed with a vigilant eye for "fake news." Through the years, I've accumulated countless stories of charted details about patients' histories and diagnoses that, upon closer reexamination, turned out to be untrue.

Take, for example, a young man who was hospitalized with "posttraumatic stress disorder" related to an "injury from a rocket launcher" in military combat overseas. Although that history was charted over and over again through copy and paste, when I sat the patient down to discuss the details, it turned out he'd merely sustained a rotator cuff injury after throwing a grenade during a basic training exercise stateside. No rocket launchers, much less PTSD, to speak of.

Too often, copying and pasting in the EMR becomes a digital variant of the telephone game, with information that was initially misinterpreted or misdocumented subsequently set in stone by perpetual duplication. That kind of misinformation fuels inaccurate diagnoses and can lead to inappropriate and unnecessary treatment.

Too often, copying and pasting in the EMR becomes a digital variant of the telephone game, with information that was initially misinterpreted or misdocumented subsequently set in stone by perpetual duplication.

Beyond the potential unreliability of charted information, copied-and-pasted admission notes often represent an incomplete summary of the chart to date, with important historical information left uncovered. Although a copied-and-pasted note containing imports from multiple sources may create the illusion of being comprehensive, it disincentivizes clinicians from performing a thorough chart review.

In my occasional work as a forensic psychiatrist, I once reviewed a malpractice case involving antipsychotic-associated ketoacidosis that could have been prevented had the treating clinician found evidence of a previous episode in the older medical record. Clinical disasters and malpractice lawsuits aside, obtaining a complete history that delves deeper than the latest copied-and-pasted admission note often yields key information to inform the best treatment decisions. A thorough medication history, for example, depends on an accurate accounting of past trials, including dose, duration, and treatment response, but this information is all too often missing from copied-and-pasted synopses.

No doubt, forensic work and a more than average dose of obsessionality have fueled my aversion to copying and pasting and made me a more careful documentarian in my clinical work. The remaining challenge for me, as an attending physician in a teaching hospital and associate training director of a residency program, is how to impress upon a new generation of physicians that my disdain for cutting and pasting isn't just some old-school fixation, and that it should in fact be avoided for the plague that it is.

I'd like to think that current generations of trainees still buy into the premise that learning how to gather detailed patient histories and assimilate that large mass of data into a coherent patient assessment is a vital part of medical school and residency education. But I'm less confident that they can be convinced that copying and pasting stifles the kind of independent thinking that's required to develop good case formulation skills and form their own opinions, just as I doubt they would readily agree that responding to attendings' questions in rounds by looking the answer up on their cellphones defeats the purpose of asking in the first place.

The published literature on the subject seems to agree with me. High rates of copying and pasting have been detected by other investigators, who have summarized the perils of the practice in greater detail than I have here,[2,3,4,5] as well as expressed similar feelings of frustrated nihilism in trying to get residents to stop doing it.[6] But would citing the consensus of other authors—no doubt from a predigital generation, like me—mean anything to today's trainees?

Probably not. Although a special report from the ECRI Institute[7] provided a comprehensive review of the problems associated with copying and pasting, it also conceded that there is sparse evidence (and little study beyond anecdotal accounts) that copying and pasting has a clear impact on adverse clinical events. Just so, physicians who use copying and pasting appear to be predictably unconcerned about the practice, not believing that it negatively affects patient care.[2]

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