Despite the risks associated with copying and pasting patient information into EHRs, new research shows more than 80% of the text in progress notes is either carried over or imported by clinicians.
Researchers at the University of California San Francisco Medical Center reviewed more than 23,000 progress notes over an eight-month period. On average, clinicians manually entered just 18% of the text in each progress note, while 46% was copied and 36% was imported, according to results published in JAMA Internal Medicine.
Residents manually entered slightly less text (11.8%) and copied slightly more. Hospitalists entered 14% of text manually.
The National Institute of Standards and Technology (NIST) has said copy and paste functionality within EHRs allows inaccurate information to persist throughout a patient’s medical record. The ECRI Institute has repeatedly warned providers about the patient safety concerns associated with duplicating information in EHRs.
Although UCSF researchers cautioned that the study was limited to one medical center, they said an EHR redesign could limit the amount of information that is pasted from previous notes.
“This finding could spur EHR design that makes copied and imported information readily visible to clinicians as they are writing a note but, ultimately, does not store that information in the note,” the authors wrote. “For example, copied text used as a hospital course record to facilitate the creation of a discharge summary may represent an opportunity for the EHR to provide an alternative space for discharge information.”