Electronic medical records (EMR's) have been hailed as the greatest thing since the X Ray in medical circles. For those unfamiliar, they are replacing the age old handwritten records with entries entered and stored on a computer. The theory is that gone are the days of chicken scratch handwriting, and an added benefit is electronic access to a patient's medical chart from remote areas outside the hospital, for example.
The reality is not matching the hype. First, simply reading and dechpihering electronic medical records in Ohio personal injury and malpractice cases we investigate has often become the equivalent of cracking a WW II German Enigma Machine message (used for the encryption and decryption of secret messages for those interested in useless trivia).
It can be a maddening exercise, due to the fact that there is a ton of repetitive "programming" information repeated on many pages of a patient's chart. Looking for anything of substance is like finding a needle in a haystack. It may make sense to the Information Technology guys and gals who developed this software, but for anyone else it's maddening.
And now this: EMR's have begun to foster a widespread practice of medical personnel "copying and pasting" a patient's previous diagnosis or vital signs and may be affecting patient care. According to a recent medical study in Ohio, 82% of residents' notes and 74% of attending physicians' notes included 20% or more copied and pasted material from the patients' records.” The study of 135 patients' records utilized plagerism detection software to pick up on this alarming practice. In one case:
“...a patient left the ICU and was readmitted a couple of days later. The patient's medical record included so much copied and pasted information, the new team of doctors wasn't able to decipher the original diagnosis. In the end, the new team called the physicians who originally diagnosed the patient.”
So--too busy to re-check the patient's vital signs and whether he or she is getting better or worse two or three hours after a physician's order? Just copy and paste the previous vital signs into the patient's record and move on. Don't think this happens? Think again. This study is spot on with what we are seeing with our own eyes as we review electronic records in our own practice.
Simply put, this new technology is subject to being abused in a hospital or other setting where patients are being moved through a system. We need no study to know that the practice of medicine has become a volume business. New technology can be a good thing and EMR's are no different, as they bring many benefits to the table regarding patient care. But like any new technology, it is subject to abuse.
It is admirable that certain medical professionals are beginning to address a problem we already are beginning to see: "copy and paste" medical care and treatment.