- Providers may be heightening the risk of patient harm by entering repetitive and inaccurate EHR clinical data into physician notes.
A recent study by Wang et al. used a new Epic EHR update allowing users to identify the provenance of data in provider notes to determine how much information is manually entered, imported from another source, or copied from previous notes.
The researchers at the California San Francisco Medical Center examined 23,630 notes written by 460 clinicians and used the update to determine which method providers used to enter EHR clinical data.
The study analyzed inpatient progress notes by direct care hospitals, residents, and medical students over an 8 month period from Jan. 10, 2016, to Aug. 31, 2016.
According to analysis, 10 percent of the text was manually entered, 46 percent was copied, and 36 percent was imported. Demographically, residents manually entered only 11.8 percent of the text and copied 51 percent of the text as opposed to medical students, who manually entered 16.2 percent of the text and copied 49 percent.
Direct care hospitals fell somewhere in the middle, manually entering 14 percent of the text and copying 47 percent. Researchers also found direct care hospitals wrote the shortest notes of all groups while medical students wrote the longest.
Provider notes are a valuable component of EHR clinical data, offering a personalized snapshot of a patient’s health condition from the point of view of the clinician.
However, EHR systems allow providers certain shortcuts that may reduce the personal touch normally associated with these notes.
“The traditional goal of progress notes is to provide a concise, up-to-date reflection of the patient’s condition and the clinician’s thought process,” noted researchers in the report. “Electronic health records (EHRs) allow physicians writing these notes to supplement traditional manual data entry with copied or imported text.”
While many clinicians see copying and importing text as largely harmless, researchers warned the shortcut may pose a potential threat to patient safety.
“Copying or importing text increases the risk of including outdated, inaccurate, or unnecessary information, which can undermine the utility of notes and lead to a clinical error,” researchers stated.
With such significant percentages of physician notes being copied and pasted into patient EHRs, the likelihood information will be repetitive, redundant, and nonspecific is relatively high.
“Less than one-fifth of note content was manually entered, a finding that was difficult to obtain with previous methods,” stated researchers in the discussion of the report.
While the study did not make any determinations regarding how much copied and imported data in provider notes affects patient safety, the inclusion of data provenance capabilities in EHRs opens the door to further investigation.
Researchers plan to continue additional studies along the same lines in the future, including a study on how copied and imported text fulfills different functions of a note, such as billing or clinical history recall.
With additional information from future studies, researchers intend to encourage innovators to modify EHRs so that providers can view copied information but omit the potentially repetitive data from final physician notes.
Providers would have the opportunity to consider information from previous physician notes while entering data into another patient EHR without saving the information and risking redundancy.
“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,” researchers stated.