Will the new electronic medical record system turn out to be a double-edged sword? This is a major concern in the light of fresh news appearing day by day on the shortcomings of the new system. The new danger is in connection with doctors copying and pasting old, outdated information into patients’ electronic records, as revealed in a new study carried out by Dr. Daryl Thornton, assistant professor at Case Western Reserve University School of Medicine in Cleveland and his team.
A report on this study points out the grave issues such as medical errors and miscommunication that could result from doctors copy-pasting information. Dr. Thornton expresses his concern at electronic medical records perpetuating copying rather than making documentation easier. His team studied 2,068 electronic patient progress reports created by 62 residents and 11 attending physicians in the intensive care unit of a Cleveland hospital. The team utilized plagiarism-detection software to analyze five months’ progress notes for 135 patients. They found that 20% or more of information was copied and pasted in 82% of the residents’ notes and 74% of the physicians’ notes.
- The immediate risk posed by this practice is that if a new team of doctors were to look at a patient’s medical records, they would contain so much of copy-pasted material that an accurate understanding of the original diagnosis would be impossible.
- Electronic medical records no longer seem to serve their purpose of clear communication when healthcare professionals bombard them with confusing medical data.
- Moreover, there is a strong possibility of documentation errors being carried forward in electronic records too.
- What physicians and residents that indulge in copy-pasting tend to forget is that irrelevant old information is best left out when records are updated.
Electronic health records have been introduced to avoid hassles related to written medical records, and facilitate easily accessible, easy-to-read, standardized documents. Given that, issues stemming from the very features of the EHR beat the purpose. One tends to doubt the feasibility of the new system if the medical records are still going to remain complex and unwieldy as before. Ambiguities in medical records may also make the medical record review process difficult. Clinicians must exercise more caution when using the new system to ensure clarity in the medical records. A little extra care will help in clearly communicating the patient’s diagnosis and the various reasons for specific clinical interventions. This will surely benefit all members of the healthcare team.
