The electronic health record offers numerous advantages over its paper counterpart: the ability to access a chart from any location; the opportunity for multiple viewers to read or contribute to a chart simultaneously; legibility; and the ease of incorporation of data into the note, without transcription error. Electronic charting is not without its pitfalls, however. Typing progress notes can be cumbersome, especially if data are not accessed easily while composing the note. Free terminals might be unavailable, and notes can disappear with the wrong click of a mouse.
Information specialists have attempted to design electronic records in a way that eases use and supports decision making.
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Computerized physician order entry is an example of a technology that generally has been viewed favorably but is not without its perils.3
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Charting would seem to be a simpler issue, largely focusing on simplicity for the user and data capture for the extractor. But unlike computerized physician order entry, where all share the goal of ordering the correct medication at the correct dosage, documentation reflects the training and perspective of the professional who is recording the data.One of the most egregious dangers of electronic charting lies not in a deficiency but in a feature, the copy-and-paste function, which allows an author to copy information from a prior note and paste it into a new note. Although physicians generally fail to perceive its negative impact,
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the copy-and-paste function has led to a number of unexpected problems and concerns about electronic note writing8
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and its impact on the culture of medicine,10
including reducing the credibility of the recorded findings, clouding clinical thinking, limiting proper coding, and robbing the chart of its narrative flow and function.Why the Copy and Paste Function is Hazardous
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 hospital course.
These notes not only fail to reflect the orderly progression of thought and action (how diagnoses are generated and the patient progresses) but also rarely provide clear documentation of the day's events or the appropriate medical diagnoses to enable the attending to link to them for billing purposes.
House Staff Copy Each Others' Notes and Errors
We have seen interns copy resident notes, consultants copy admission notes from the primary intern, and interns who are beginning a new service copy the previous intern's note. With each iteration, notes lengthen and errors accumulate.
Narrative Function Is Lost
Another more insidious consequence of the copy-and-paste function has been the loss of the narrative. Because charts have become capacious warehouses of disorganized, irrelevant, or erroneous data, the story of the patient and the patient's illness is no longer easy to read or likely to be read. In a most compelling and perhaps unintended way, we are witnessing the “death” of the health record narrative, as many of us have known it. Others also speak of the loss of narrative in electronic health records,
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and with great concern because narratives form the basis of clinical decision making.12
Daily documentation of the patient's trajectory, in prose, even when stripped of overt emotional content, is not just educational. It is humanizing. We suspect that the growing interest in the creation of parallel charts and diaries
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to help physicians and medical trainees process the multidimensional work of medicine and cope with the stresses of patient care stems at least in part from the loss of the narrative power of the true chart.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 of hectoring will change that. They cannot be faulted for thinking that doing the actual care is more important than writing about it, especially when they may have a dozen notes to write each day.
Disabling the copy-and-paste function might eliminate many of the problems that we have encountered with house staff documentation, but we have noted that resourceful house staff can copy/paste from documents saved in text format outside of the electronic chart; they no doubt will find other ways to overcome barriers. We must realign their incentives so that documentation has meaning—for the patient and those providing the care. One idea that would not require reprogramming would be to change the nature of the house staff progress note. Admission histories and physical examinations would remain the same, comprehensive and complete. To document progress, however, interns could write a brief narrative, describing the events and plans for the day. Residents could write a structured note on a core of patients, with the explicit goal of learning how to document accurately and how to bill correctly. Attendings, in exchange for strong house staff notes to which they can link, could spend more time clarifying or amplifying and less time in duplicative efforts. The chart would reflect the differing perspectives of all its physician contributors, and the notes might add up to a more complete and more satisfying whole.
The Future of Electronic Charting
At present, the literature about the impact of health information technologies is limited in its scope and generalizability.
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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 communication in health care and states that informatics systems have largely ignored this interface.Calls to make the chart more like social networking sites
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show insight into the need to think creatively about charting as a communications tool; nonetheless, we would argue that the chart first and foremost is a permanent, written record of a patient's hospital course: a legal document. Its reliability is likely to deteriorate further if the informal culture of social networking is allowed to permeate the health system.Although the electronic health record has enormous potential, we must understand and document its impact on essential functions within the culture of medicine. Only then can we understand how to proceed. Clinicians, administrators, and hospital counsel must collaborate more closely with informatics designers to create an electronic health record structure that promotes the functions we value within our medical culture while fostering a respect for the chart's permanence. An electronic health record can document a patient's course, foster meaningful patient narratives, free up more time for direct patient contact, and advance care by enhancing both intradisciplinary and interdisciplinary communication. To do so, we must change not only the health record but also the way we create it, evaluate it, and use it.
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Footnotes
Funding: None.
Conflict of Interest: None.
Authorship: Both authors played a role in writing the manuscript.
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© 2009 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
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- Copy and Paste of Electronic Health Records: A Modern Medical IllnessThe American Journal of MedicineVol. 123Issue 5
