EditorialCopy and Paste: A Remediable Hazard of Electronic Health Records
Section snippets
Problem Lists Never Change
House staff have recognized that if they organize problems by system (eg, gastrointestinal; fluids, electrolytes, nutrition; cardiovascular), they can copy and paste the same problem list day after day, even if new diagnoses appear or priorities have changed. The lists contain updated information, but they do not reflect what is new, different, or important. If “pulm” was the most important problem on day one, it will remain first on the list through the admission, irrespective of the patient's
Corrective Action
Why do smart, caring, dedicated, and skilled physicians write such conspicuously deficient notes? Can we change the behavior? Attending physicians tend to view charting as a means of justifying the bill and reducing liability risk. House staff are focused on direct patient care and consider the note a low priority chore. They do not bill. Few of them have endured a deposition. As a result, their understanding of the purpose of the health record differs from that of the attending, and no amount
The Future of Electronic Charting
At present, the literature about the impact of health information technologies is limited in its scope and generalizability.16 Electronic health record systems have been developed for many purposes, and it is crucial to make sure these “tools” advance the values we want medicine to be and reflect rather than undermine important components of medical culture, such as communication between house staff and nursing staff and faculty. Coiera17 acknowledges the primary importance of clinical
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2021, Currents in Pharmacy Teaching and LearningCitation Excerpt :Instructors also expressed wariness that student learning might shift away from being clinically-driven and instead focus solely on navigating the tEMR. Interestingly, these challenges in pharmacy education are similar to concerns that have been identified with clinical practice EMRs based on reports of EMRs altering clinical workflow and diverting clinicians' time away from direct interactions with patients.35–40 Additionally, instructors reported difficulties with the usability of the tEMR for themselves and students; while design and usability vary somewhat across all EMRs, it is well documented that the usability of clinical practice EMRs is poor, with United States clinicians assigning EMRs an “F” grade.41
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2021, International Journal of Medical InformaticsCitation Excerpt :It has been reported that electronic notes created in the U.S. are significantly longer than similar documentation in other developed countries [11], often contain redundant information and errors [12,13], and in some cases may never be read [14]. Part of the problem is attributed to the practice known as “copy-and-paste,” frequently used by clinicians to alleviate documentation burden [8]. Others suggest that more complex billing requirements force providers to document non-clinically relevant data in their notes [11], leading to longer notes and frustration [15].
Data gaps in electronic health record (EHR) systems: An audit of problem list completeness during the COVID-19 pandemic
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Funding: None.
Conflict of Interest: None.
Authorship: Both authors played a role in writing the manuscript.