EHR notes and the cut and paste documentation problem

“Detritus.”

Not only was that a chance for the Disease Management Care Blog to refamiliarize itself with an underused noun (and, er, its spelling), that was the telling term used today by a DMCB colleague to describe the output from a local health system’s electronic health record (EHR).

He had received a copy of a lengthy consultant-physician’s documentation involving one of his patients and was astonished by the blob of past data, prior notes, test results, excerpts, quotes, interpretations and correspondence that had been replicated word-for-word in the course of “seeing” his patient. The terse portions describing what the patient actually said, what the consulting doctor actually examined and what the diagnosis and plan were were inconspiculously buried toward the end of the EHR document.

This was a classic case of electronic record “CoPaGA” i.e., Copy ‘n Paste Gone Amok Syndrome. Characterized by repeated highlighting, copying and pasting text from past EHR notes into current notes, the physician-victim attains several goals simultaneously: 1) avoiding the time-consuming work of having to talk to a human being, 2) building a long trail of documentation that portrays faux work effort and 3) justifying a maximally remunerative fee.

Other symptoms of CoPaGA are well described in the medical literature such as JAMA here in the Archives here. They include the crowd-out of useful information by gluts of useless data-text and the endless zombie-like propagation of inaccuracies that refuse to go away. The problem is significant enough that a methodology exists to measure just how severe it is. Last but not least, it’s also important to recognize that the words “seeing” and “patients” in context of CoPaGA is a contradiction in terms, since afflicted docs typically spend little time actually looking at patients. They’re too busy looking at the monitor!

Contrast this with these New England Journal authors’ promise of EHRs preventing diagnositic errors through, “serving as a place where clinicians, together with patients, document succinct evaluations, craft thoughtful differential diagnoses, and note unanswered questions. Free-text narrative will often be superior to point-and-click boilerplate in accurately capturing a patient’s history and making assessments, and notes should be designed to include discussion of uncertainties.” (italics DMCB).

Will the proposed ‘meaningful use’ HITECH regulations (which can be seen here) be able to combat CoPaGA and solve the problem of the substitution of input for insight by EHR addled physicians? That remains to be seen, but given the incurabilty of CoPaGA and the eternal nature of detritus (spelled with two t’s), the DMCB thinks the prognosis is bleak.

We’ll see.

Jaan Sidorov is an internal medicine physician who blogs at the Disease Management Care Blog.

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