Monday, January 7, 2013

Research published on "copy and paste" in EHR progress notes

We all use copy and paste, don't we? I love my Ctrl+C, Ctrl+V keyboard commands.

Although it's easy and convenient to use copy/paste, clinicians should not use these commands when entering patient notes.

Thornton, J. Daryl MD and others published some research findings evaluating the "Prevalence of Copied Information by Attendings and Residents in Critical Care Progress Notes."

Here's the abstract:

Objectives: To determine the prevalence and mechanism of copying among ICU physicians using an electronic medical record.

Design: Retrospective cohort study.

Setting: Medical ICU of an urban, academic medical center.

Patients: Two thousand sixty-eight progress notes of 135 patients generated by 62 residents and 11 attending physicians between August 1, 2009, and December 31, 2009.

Interventions: None.

Measurements and Main Results: Eighty two percent of all residents and 74% of all attending notes contained greater than or equal to 20% copied information (p = 0.001). Although residents authored more copied notes than attendings, residents copied less information between notes than attendings (55% vs. 61%, p < 0.001). Following greater than or equal to 1 day off, residents copied less often from their own prior notes compared to attendings (66% vs. 94%, p < 0.001). Of the copied information following a day off, there was no difference in the amount of information copied into notes of residents (59%) or attendings (61%, p = 0.17). In a regression model of attending notes, no patient factors were associated with copying. However, the levels of copying among attendings varied from 41% to 82% (p < 0.001).

Conclusions: Copying among attendings and residents was common in this ICU-based cohort, with residents copying more frequently and attendings copying more information per note. The only factor that was independently associated with attending copying was the attending. Further studies should focus on further elucidating the factors influencing copying in the ICU and the effects of copying on patient outcomes.

Thornton JD, Schold JD, Venkateshaiah L, Lander B. Prevalence of Copied Information by Attendings and Residents in Critical Care Progress Notes. Crit Care Med. 2012 Dec 20.
PMID: 23263617

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