With copy and paste rampant, UW Health chief medical information officer Shannon Dean says toolkits and vendors can help, but physicians need to take responsibility for proper clinical documentation.
Overuse of copy and paste in electronic health records is a problem. Sure, it’s convenient. And it’s entirely understandable why it’s a common shortcut used by scores of physicians. But it often results in note bloat – unwieldy patient records overflowing with repetitive documentation – that can potentially lead to serious safety risks.
“Copying or importing text increases the risk of including outdated, inaccurate, or unnecessary information, which can undermine the utility of notes and lead to a clinical error,” wrote researchers in a 2017 study in Journal of the American Medical Association.
The practice of copy and paste has to be reigned in, and one chief medical information officer, writing for the Agency for Healthcare Research and Quality, says that has to start with the physicians themselves.
Shannon Dean, MD, CMIO at University of Wisconsin School of Medicine and Public Health, penned a column this month for AHRQ’s Perspectives on Patient Safety. She began with an example of what can happen when notation gets lazy.
She cites the case of a 78-year-old man who, “with an alleged history of ‘PE’ (interpreted by the clinicians as pulmonary embolism) received an unnecessary CT scan to rule out a suspected ‘recurrence’ of pulmonary embolus.
“As it happens, years earlier, the abbreviation ‘PE’ had been used in the electronic note to indicate that the patient had had a physical examination, not a pulmonary embolism!” said Dean. “In a vivid example of copy and paste, once the diagnosis of pulmonary embolism was mistakenly given to the patient, it lived on in the EHR.”
Beyond the risks to patient safety, that also points to the unnecessary costs that can pile up when unwitting clinicians order tests that are based on erroneous and repetitive data.
Nonetheless, said Dean, too many clinicians still copy and paste as a habit: “Perhaps we are complacent about copy and paste because we remain unconvinced that there is a correlation between its use and patient safety.”
In her article, she surveys more than a dozen studies on the subject, and finds that published research into adverse outcomes isn’t as voluminous as one might expect, even if it’s understood, intuitively, that the practice isn’t ideal.
So “it is clear that much work remains to be done,” said Dean. She points to toolkits like the one put together by AHIMA, and the fact that Epic has rolled out functionality that can “identify the source of every character within a note, whether it is newly typed, imported from another source, or copied and pasted.”
Still, “I am aware of very few organizations that are actively using these tools to educate and mentor clinicians in a systematic way to improve documentation quality,” she said.
While more academic research would be welcome on the correlation between copy and paste and patient safety, she said, it’s fairly widely accepted that it’s a shortcut that should only be used sparingly and in specific instances.
Healthcare organizations need to start making use of resources such as AHIMA’s toolkits, Epic’s auditing features and innovations like natural language processing technology to help physicians do better with their EHR documentation.
She also points to the OpenNotes initiative, which continues to gain momentum, as another big opportunity: Giving patients the ability to read their own doctor’s clinical notes allows them to “hold us accountable for quality documentation.”
But at the end of the day, “physicians need to reestablish ownership of the accuracy of clinical documentation,” said Dean. “We must stop blaming the EHR for our carelessness and start educating ourselves about how to use documentation efficiency tools, including copy and paste, more responsibly.”
According to a new study, U.S. doctors spend nearly 17 percent of their working lives on nonpatient-related paperwork — time that might otherwise be spent caring for patients. The findings also suggest that the more time doctors spend on such tasks, the unhappier they are about having chosen medicine as a career
This data comes from new research conducted by Drs. Steffie Woolhandler and David Himmelstein, internists in the South Bronx who serve as professors of public health at the City University of New York and are lecturers in medicine at the Harvard Medical School. The results of the study were published in October by the International Journal of Health Services.
The authors of the study analyzed data from the 2008 Health Tracking Physician Survey (the most recent data available) that collected information from a national sample of 4,720 physicians practicing at least 20 hours per week. The researchers determined that an average doctor spends more than eight hours per week performing administration functions.
However, of note is the fact that this does not include time spent performing patient-related tasks like writing chart notes, communicating with other doctors and ordering labs. Specifically, administrative tasks are defined as “billing, obtaining insurance approvals, financial and personnel management and negotiating contracts.”
Of the population surveyed, the doctors spent 168.4 million hours on these tasks in 2008. The authors estimate that the total cost of physician time spent on administration in 2014 will amount to $102 billion, and they pointed out that physicians who used electronic health records actually spent more time (17.2 percent for those using entirely electronic records, 18 percent for those using a mix of paper and electronic) on administration than those who used only paper records (15.5 percent).
“Although proponents of electronic medical records have long promised a reduction in doctors’ paperwork, we found the reverse is true,” the authors wrote.
The more time spent on these tasks meant physicians were less happy with their work than those who did less of this work. Psychiatrists spent the most time on administration (20.3 percent), followed by internists (17.3 percent) and family/general practitioners (17.3 percent). Pediatricians spent the least amount of time (14.1 percent) on nonpatient-related administrative tasks and also were the most satisfied group of doctors.
“While solo practice was associated with more administrative work, small group practice was not,”Woolhandler and Himmelstein concluded. “Doctors practicing in groups of 100 or more actually spent more time (19.7 percent) on such tasks than those in small groups (16.3 percent).”
They point out that the only previous nationally representative survey of this kind was carried out in 1995, and that study showed that administration and insurance-related matters accounted for 13.5 percent of physicians’ total work time. Other, less representative studies, also suggest the bureaucratic burden on physicians has grown over the past two decades.
“American doctors are drowning in paperwork,” said lead author Dr. Woolhandler. “Our study almost certainly understates physicians’ current administrative burden. Since 2008, when the survey we analyzed was collected, tens of thousands of doctors have moved from small private practices with minimal bureaucracy into giant group practices where bureaucracy is rampant.
“And under the accountable care organizations favored by insurers, more doctors are facing HMO-type incentives to deny care to their patients, a move that our data shows drives up administrative work. Administrative work consumes one-sixth of U.S. physicians’ working hours and lowers their career satisfaction.”
This study and its findings parallel that of another recent study in September that was conducted by The Physicians Foundation related to physician satisfaction with their careers. That study suggests that U.S. patients may face growing challenges accessing care if shifting patterns in medical practice configurations and physician workforce trends continue.
According to the study, titled “2014 Survey of America’s Physicians: Practice Patterns and Perspectives,” 81 percent of physicians describe themselves as either overextended or at full capacity, while only 19 percent indicate they have time to see more patients.
Of those physicians surveyed, 44 percent plan to take steps that would reduce patient access to their services, including cutting back on patients seen, retiring, working part-time, closing their practice to new patients or seeking nonclinical jobs, leading to the potential loss of tens of thousands of full-time-equivalents.
“America’s physician workforce is undergoing significant changes,” said Walker Ray, M.D., vice president of The Physicians Foundation and chair of its Research Committee. “Physicians are younger, more are working in employed practice settings and more are leaving private practice. This new guard of physicians report having less capacity to take on additional patients.
“These trends carry significant implications for patient access to care. With more physicians retiring and an increasing number of doctors, particularly younger physicians, planning to switch in whole or in part to concierge medicine, we could see a limiting effect on physician supply and, ultimately, on the ability of the U.S. healthcare system to properly care for millions of new patients.”
The survey is based on responses from 20,088 physicians across the U.S.
“The state of the physician workforce, and medicine in general, is experiencing a period of massive transition,” said Lou Goodman, Ph.D., president of The Physicians Foundation and CEO of the Texas Medical Association. “As such, the growing diversity of the physician workforce will reflect different perspectives and sentiments surrounding the state of medicine.
“While I am troubled that a majority of physicians are pessimistic about the state of medicine, I am heartened by the fact that 71 percent of physicians would still choose to be a physician if they had to do it over, while nearly 80 percent describe patient relationships as the most satisfying factor about practicing medicine.”Monday, November 10, 2014
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Electronic health records ripe for theft
America’s medical records systems are flirting with disaster, say the experts who monitor crime in cyberspace. A hack that exposes the medical and financial records of hundreds of thousands of patients is coming, they say — it’s only a matter of when. As health data become increasingly digital and the use of electronic health records booms, thieves see patient records in a vulnerable healthcare system as attractive bait, according to experts interviewed by POLITICO. On the black market, a full identity profile contained in a single record can bring as much as $500.
“I think the health data stewards are probably a little behind in the race. The criminal elements are incredibly sophisticated.” READ MORE
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