When it comes to patient records, doctors guilty of the old copy-paste

January 10, 2013 article on CNET.com by Elizabeth Armstrong Moore

A new study finds the majority of doctors copying potentially out-of-date information from previous notes and other documents and pasting them into patient progress reports.

Ah, the old copy/paste. Such a handy keyboard shortcut for such a wide range of applications. But would you want your doctor using it while maintaining your oh-so-personal and unique-to-you medical records?

Because chances are good that your doc does, according to new research out of Case Western Reserve University School of Medicine. Excuse me while I take a moment to summarize, rather than copy and paste, some key findings from the research.

Assistant professor of medicine and lead author Daryl Thornton and his team scrutinized 2,068 electronic patient progress reports at an ICU in Cleveland. Some 62 residents and 11 attending physicians had their gloved hands in these documents over the course of five months as they updated the files of 135 patients.

Thanks to software typically used to detect plagiarism, the researchers found that 82 percent of residents’ notes and 74 percent of attending physicians’ notes contained material that had been copied from previous records or other documents. And the offending “material” was not just a phrase or two; at least 20 percent of the records had been inserted from elsewhere.

While the copying behavior may range from harmless time saving to the insertion of downright erroneous information, the researchers readily admit that they set out to find prevalence of copying and did not delve into why the physicians did this or what effect, if any, this behavior has on actual patient care.

And now, if I may be so bold as to copy from the study itself, the researchers conclude: “Further studies should focus on further elucidating the factors influencing copying in the ICU and the effects of copying on patient outcomes.”

For now, if you’d like to catch your own doctor in the act, simply request your medical records and see if they are current and appear to be about you. You should be able to see most of the notes, though in some states, such as New York, the physician can deny access to his or her “personal notes and observations.”