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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  • http://twitter.com/faisal_q Faisal Qureshi

    Not sure if MU will change CoPaGA behavior. MU was designed to track outcomes without regard to documentation volume. All EMR systems support templating and even advise it during training.

  • Doc99

    “Garbage In = Garbage Out ” is not a new concept.

  • http://legmed@aol.com Hugh Hill

    If you actually review the data being pasted, then it seems appropriate to claim credit for complexity in billing coding. But even if you review it, you are not independently verifying it. I worry about error perpetuation, and thus multiplication. Perhaps we need to cite sources when they are not obvious for the cut and pasted info.

  • jsmith

    I just got back hospital notes from a 3 week burn unit admission. One new subjective line each day –Pt has no complaints. PE: no change. Plan: Continue to monitor for wound demarcation. Fine, not much happening I guess, but then each note had 2 pages of repeating what each previous day said, all the meds, all the allergies, the PMH, etc. A waste of paper and a waste of the reader’s time.
    I was trained years ago that notes were written to communicate important clinical information and were to omit irrelevant information. Things are different now.

  • alex

    It is literally impossible to run a practice where you both generate new data every time in an EMR and fulfill all of the byzantine documentation requirements of Medicare. Once again, the root of the problem is Medicare forcing us to document excess information to get paid. Is it really news that people aren’t going to sit there and type documentation for longer than the duration of the appointment?

  • Jenga

    Wrong, notes are written to fulfill E&M requirements. Silly physicians, and you thought it was actually about treating the patient.

    Sincerely,
    CMS

  • rwatkins

    This is called “lying for dollars.”

    It is a tremendous ethical problem that no one in the medical or EHRs professions is willing to address.

    The MAIN selling point that EHR vendors still use in approaching private practice physicians remains the supposed increased revenue from higher levels of coding.

    Coding and documentation requirements have inextricably polluted medical records in the United States. This pollution is only worsened by EHRs that link every piece of data entry to possible increased billing levels.

  • http://diseasemanagementcareblog.blogspot.com/ Jaan

    Wow. Excellent comments. Based on them, I’m learning meaningful use regulations will NOT address the glut of repetitive useless documentation, that’s it’s POSSIBLE that someone is actually using all the information (and thus appropriately billing for it), that it’s not just the physicians’ fault plus there are dysfunctional incentives at work. It would also appear that this is not a small problem confined to some corner of medical practice and that it may be time for physicians to show some leadership in this area by insisting on systems that help us be better doctors for our patients.

  • Paul

    Jaan, this is a great post.

    Since we ID doctors are obsessed with detail, I just cited it here:

    http://blogs.jwatch.org/hiv-id-observations/

  • http://www.heartlandclinic.org/plattecity David Voran

    One sure way I’ve found to resist the GoPaGa or GIGO temptation is to make sure the patient sees the note being created at the point of care. We do this in the office and often have to redact information that gets sucked into the note from the chart automatically.
    By sitting down with side-to-side with the patient and having the note reviewed and understood by the patient produces a complete and accurate note that does fulfill the right-documentation for E&M coding as well as conveys the right information for downstream readers.
    It’s a work flow issue and one that does not add to the time of the visit and works reasonably well until you exceed 5 patients per hour when it begins to break down. But then I think there’s evidence that shows deterioration in medical decision making when more than 4 patients an hour are being seen.
    It is true that more information is conveyed when documenting less and we should all be trying to maximize the signal to noise ratio in everything we do in order to improve care.