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EMR copy and paste: Is there really a problem?

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EMR EHR copy and pasteIf you are old enough to remember the days before word processors, you remember how difficult writing an essay for school was: erase, white out, re-write.  Word processors have loosened the electronic tongue of all writers, including doctors, so that writing substantial notes is no longer an arduous process.

A new paper, Prevalence of Copied Information by Attendings and Residents in Critical Care Progress Notes, published by the Society of Critical Care Medicine and Lippincott Williams & Wilkins, notes the high usage of the copy and paste function among attending physicians and residents in writing their clinical care notes for  their  EMRs and suggests it is a problem regarding integrity of records and plagiarism.  But I wonder whether we are making a mountain out of a molehill here. 

Who would use EMRs if there were no  copy and paste function?  Creating electronic medical records from scratch, having to input all data ex nihilo would take forever.  It is cumbersone enough for doctors to have to write notes at the time of their patient encounters.  One of the beauties of an EMR is it’s reporting function, whether for clinical notes or medical billing software  purposes.  The burden of medical record reporting that  rests on  physicians today thanks to  the insurance companies and the US  Government could not be handled by composing all notes from scratch for a sizable medical practice.

The whole notion of a  database rests upon not re-inventing the wheel.  When the information is available and can be imported and revised to suit our needs, the database (and the full EMR) becomes an efficient tool.  Take that away, and you may as well be asking medicine to return to the days of the electric typewriter.

As in most questions of right and wrong, the issue is in the details of a doctor’s conduct.  Is he mindlessly copying, is he robbing textbook information,  is he not thinking through this particular patient’s case,  or is he editing and revising to save time and get the facts straight?   Perhaps EMRs need to incorporate the same sort of anti-plagiarism checks that college students submitting termpapers do: an independent program checks their information against previously published material. Or perhaps a weekly review of patient notes must be required of the doctor  and time-stamped into every EMR to  check for inaccuracies both in clinical notes and in billing.  But to say that the copy and paste function should not be available to doctors writing  their clinical notes…please, spare us such tyranny!

 

 

 

 

 


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