Are electronic medical records trustworthy? Observations on copying, pasting and duplication.
As routine use of on-line progress notes in US Department of Veterans Affairs facilities grew rapidly in the past decade, health information managers and clinicians began to notice that authors sometimes copied text from old notes into new notes. Other sources of duplication were document templates that inserted boilerplate text or patient data into notes. Word-processing and templates aided the transition to electronic notes, but enabled author copying and sometimes led to lengthy, hard-to-read records stuffed with data already available on-line. Investigators at a VA center recognized for pioneering a fully electronic record system analyzed author copying and template-generated duplication with adapted plagiarism-detection software. Nine percent of progress notes studied contained copied or duplicated text. Most copying and duplication was benign, but some introduced misleading errors into the record and some seemed possibly unethical or potentially unsafe. High-risk author copying occurred once for every 720 notes, but one in ten electronic charts contained an instance of high-risk copying. Careless copying threatens the integrity of on-line records. Clear policies, practitioner consciousness-raising and development of effective monitoring procedures are recommended to protect the value of electronic patient records.
Hammond
Kenric W
KW
US Department of Veterans Affairs Puget Sound Health Care System, Seattle and Tacoma, Washington, USA.
Helbig
Susan T
ST
Benson
Craig C
CC
Brathwaite-Sketoe
Beverly M
BM
D006787:Hospitals, Veterans / Q000458:organization & administration; D006801:Humans; D008485:Medical Audit; D016347:Medical Records Systems, Computerized / Q000592:standards*; D016134:Organizational Policy; D011785:Quality Assurance, Health Care; D014481:United States