We are in the age of copy and paste medicine

I’ve been working with the latest electronic medical record (EMR) for almost a year now. You know the one. There are many positive changes, to be sure. It has helped me more than a few times with calculating doses for kids’ medications. I can now easily check in on my patients’ progress when they are admitted to the hospital. And, of course, the notes are far more legible.

But what do the notes actually tell me? Sadly, sometimes, not much.

We are in the age of copy and paste medicine, an unintended (I hope) yet predictable consequence of the EMR. I see it on the outpatient side, but it was really driven home after my latest stint on the pediatric ward. There, I see the patients every day. Their status changes. But, sometimes the notes don’t. It’s little things — like a patient who’s been extubated for a couple days but still has vent settings in the note. Or a note (written using a template) that tells me that a 17-year-old’s fontanelle is closed. Technically true, but definitely hasn’t been relevant for about 16 years.

But it’s the assessments, or lack thereof, that really get me. My favorite part of the progress note, the assessment, tells me how the patient is doing. Better? Worse? Clear diagnosis? Still up for debate? What’s more, when I’m working with trainees it shows me how (and whether) they are thinking. It helps me to know whether they understand why we are doing what we’re doing. In the EMR the assessment often degenerates into a computer-generated problem list without any particular assessment by the author of the note. Or, a cut and paste of the assessment from a colleague that is a few days old, not adjusted for what we’ve learned and decided since admission.

But, don’t think this is just affecting trainees. It happens at all levels, and to even the most conscientious of physicians. When following a high number of patients on a given day it gets very difficult to review every single line of a long note or catch every needed change. The sheer amount of documentation we are now asked to do for each patient encounter often makes me feel that the system values quantity over quality. The best note I read recently as ward attending came from an unlikely source, the attending surgeon. Only a few lines long, it likely didn’t meet criteria for “meaningful use,” but it told me what I needed to know. I quickly gleaned the surgeon’s opinion about how this patient was doing clinically, their thoughts on the most likely diagnosis, and whether they felt the patient needed surgery.

I can’t help thinking that current medical practice stands in stark contrast with the type of medicine described by Victoria Sweet in her wonderful book, God’s Hotel. She describes a slower kind of medicine, with focus on the patients and time to “just sit”:

… after Ms. Gilroy, I took the time to “just sit” in this way with all my patients. Especially if they took a turn for the worse, or if a nurse or family member was worried that something wasn’t quite right. I would leave my cell phone in the nursing station, turn off my beeper, move a chair next to the patient, and sit down. Not for long- five or ten minutes. Sometimes the patient would want to chat, and we would chat, and sometimes I would study the patient’s face, bedclothes, and bureau. But mostly I would just sit. And something, somehow, would happen. It would become clear what, if anything, was wrong with the patient and what, if anything, I could do about it.

Instead of this experience, new doctors are sitting with computers.

I remain hopeful that we are simply in version 1.0 of all of this. That future iterations will bring improvement and a return to more a patient-centered and provider-friendly form. That technology will begin to help rather than hinder. And, I’m certainly grateful that I can now easily read the consult note that previously remained mysterious until a conversation with its author. But I can’t help feeling a bit nostalgic for the good ol’ days.

Heidi Roman is a pediatrician who blogs at My Two Hats.

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  • southerndoc1

    “I remain hopeful that we are simply in version 1.0 of all of this. That future iterations will bring improvement and a return to more a patient-centered and provider-friendly form. That technology will begin to help rather than hinder.”

    Why in the world would you think that? Do you imagine ICD-10 and MU 3 are going to make things better? Come on, be a scientist: look at the facts and deal with reality. Sitting around hoping things will somehow magically get better is exactly the kind of thinking that has gotten us in this mess.

    • buzzkillersmith

      Hopeful?? Bless her heart.

  • betsynicoletti

    I think it’s important to differentiate what part of the clinical note is useful if copied and what parts add to confusion. I think we can all agree past medical, family and social history can be reviewed and imported. The clinical summary that is often the start of the HPI can be imported. “this 78 y.o. woman with COPD, lung nodules, etc.” Those 2-8 sentences at the start of the note mean the physician doesn’t have to click back through previous notes to get see who is sitting in the room. After that clinical summary, however, the HPI should be new: “Since last seen, she reports…. ”

    I don’t think ROS should be imported, despite what the Documentation Guidelines say.

    Clinicians tell me that it is helpful to import that patient’s previous exam and edit it (edit it, of course) and that this is more accurate for this patient than starting with a “normal exam template.”

    There are some EHRs in which the patient’s entire problem list is used as the assessment for a hospital visit. Not helpful. Move that to PMH and put in the assessment the problems addressed by that clinician that day, and the corresponding plan. Keep in active problems being managed by someone else. “Per nephrology.” For outpatient, list problems addressed that day and the plan.

    As I was working with a client on this issue, I got this piece of advice from a physician colleague for the policy. He sums it up much more eloquently than I have, and I’ve reproduced it below.

    “The purpose of documentation is not to select a level of E/M
    service. Other healthcare professionals need to be able to treat the patient. The goal of this discussion is to protect the integrity of the medical record. When choosing an E/M level the rule is that if you did not document it you did not do it so you cannot count it. With copying and pasting notes in EHRs, the rule is that you should not document it if you did not ask it review it, examine it or consider it. If you copied from a previous note, read your new note and see if it contains any details that do not meet one of those criteria. If so, delete that element.”

    • guest

      My impression is that the doctors do not read their new notes as thoroughly as they should before finalizing signature. It is not easy when pressed for time, frequently interrupted and surrounded by usual noisy hospital environment.

      The solution is to give doctors built in time to complete the notes, tone down the hospital monitors and staff chit chat and give doctors private computer space. It would also be helpful to not page with non urgent issues but message/text instead at any time especially at 2:30 am. Sleep deprivation also adds to sub optimal focus which may aggravate things further.

      Unfortunately, in my opinion, giving doctors time for documentation, protected time and space would be more difficult than fighting against the ever growing burden of clinically irrelevant information which needs to be entered into these notes.

  • bruce quinn

    In the best case, writing – even somewhat hurried medical note writing – should have enough thought, including relatively spontaneous organization, to make a clear story and inform the reader with what he should know and needs to know. This is certainly true in a consult letter, but can be conveyed to some degree even in a daily hospital chart note. It is easy to see that being lost if the medical writer is simply confronted with a screen full of symptom names and check boxes.

    Of course, if the handwritten note were the scribbly equivalent of “better, sx wnl, nrml” then it’s not much good either, so not much is lost in the electronic conversion.

  • lord acton

    From your lips to our professions ears. I hear nothing but complaining from my colleagues. I tell them how happy I am and how happy my patients are with the direct pay primary care model….and they look at me as if I am describing a time share on Mars.

  • maggiebea

    One thing that has unfortunately been lost in the rush to put everything into predigested, uniform typeface on the screen: B I G L E T T E R S in the handwritten note to indicate something crucial. A major change in condition, a reaction to the medication started yesterday … back when one read a chart by actually flipping pages, those notes would leap out of the mass of data and abbreviations. The truly critical stuff could even be circled in red or highlighted in yellow. I wish I could teach my EMR to do that.

    And I’m only a chaplain; very few of my mistakes are deadly.

  • Deceased MD

    Can you imagine trying to get away from all this to find yourself on vacation surrounded by 40 EMR folks from Alabama that announce “I teach doctors”!!?? (Unfortunately they were staying at our hotel.) Had to leave the hot tub immediately. Just too hot in there.
    Their training was also eye opening. One fellow was previously a truck driver for bottled water who now “teaches doctors.”

  • COLONDOC

    I tweeted about this a month back – @colondoc: See what both patients and doctors have been missing. Unplugged and Reconnected http://t.co/wFG45APBnD

    The art of a well performed H&P has been lost, replaced by a swift cut and paste where events that may have occurred many days ago are pasted again and again into each new progress note.

    Most of our doctors look at a computer, rarely do they look directly at patients. For these greater efficiencies come depersonalization. We might as well have computers do the doctor’s job.

  • buzzkillersmith

    EHRs are time-sucking trash, known to be so. They won’t get much better.

    Not legible? Dictate. We could have the scribes be transcriptionists.

    But this will not happen, at least until decision makers realize that EHRs don’t improve care or save money. Until then, embrace the suffering.

  • Lynne Flaherty

    When I trained, I was taught that the medical record was a form of communication. It was important to document accurately, and most important to record one’s medical decision-making — what did I think was going on with the patient, and why was I going to do what I did?

    Today, I go into past records from my colleagues on patients I am seeing, and I’m lucky if I can even understand what happened at all. And the only way, really, is to go through the nurse’s notes and see what was ordered, what the patient got (tests and treatments). The final diagnosis and plan are skeletonized beyond understanding.

    The purpose of today’s medical record is to maximize billing. MY purpose is to maximize revenue while not causing any trouble. I miss the old days.

  • Lynne Flaherty

    Oh, and btw, there was a recent case in Washington State where a physician received sanctions from the State Medical Board for entering erroneous information in an EMR and propagating it forward — ONE case, and he got license restrictions. We all need to be careful!