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Copy-and-paste notes in EMRs detrimental to patients with diabetes
Turchin A. Arch Intern Med. 2011;doi:10.1001/archinternmed.2011.219.
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Recycling information about lifestyle counseling in electronic medical records had the same effect on HbA1c in patients with diabetes as no counseling at all, recent data indicate.
A retrospective study conducted by Alexander Turchin, MD, and colleagues revealed that copying and pasting information from previous visits into updated electronic medical records (EMRs) happens often. Among 5,914 patients with diabetes, the average number of times that duplicate documentation appeared for the same health care provider for the same patient was 3.07. In contrast, this number was lower (0.099) for the same health care provider for other patients (P<.001). The percentage of duplicate documentation was similar for diet counseling (5%), exercise counseling (5.1%) and weight-loss counseling (5.2%). An adjusted multivariable analysis also indicated that the HR for an increase in one monthly episode of any distinct lifestyle counseling was 4.35 (P<.001) for reaching target HbA1c.
“Previous research has shown that copying and pasting fragments of notes is common in EMRs,” Turchin, of the endocrine division at Brigham and Women’s Hospital and a senior medical informatician at Partners HealthCare, said in a press release. “Our study is the first to show in a systematic way that the copy-and-pasted material may not be accurate.”
Further, duplicate documentation of lifestyle counseling exerted no positive effects on glycemic control, with the researchers noting that the outcomes were similar to those when no counseling occurs. Because copying and pasting information in EMRs can have serious legal and financial ramifications, the researchers advocate efforts to curtail this problem.
“These could include training and education of health care providers, as well as technical solutions, such as software that automatically detects overly similar notes or components,” they wrote.
Disclosure: The researchers report no relevant financial disclosures.
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