EHR progress notes are intended to do just what they sound like — give physicians a chance to provide an updated analysis of a patient’s condition and progress.
For clinicians, the laborious process of manual data entry is simplified by the fact that they can copy or import bits of text. But beware, for these techniques have their downfalls. “However, copying or importing text increases the risk of including outdated, inaccurate, or unnecessary information, which can undermine the utility of notes and lead to a clinical error,” reads a research letter published in JAMA Internal Medicine.
A group of researchers at the University of California San Francisco Medical Center launched a study to investigate whether the text in such EHR progress notes is most often manually entered, copied or imported.
Due to the high number of records involved and since all the research materials were previously used for nonresearch purposes, the UCSF institutional review board waived patient informed consent for the study.
As part of the study, researchers analyzed 23,630 inpatient progress notes in an Epic EHR system between January 10, 2016, and August 31, 2016. The notes were written by 460 direct care hospitalists, residents and medical students.
The researchers’ work was made easier through a new Epic software update, which enables the EHR system to detect whether each word in the progress note is manually entered, copied or imported. The information is concealed by default, but physicians can elect to see it if desired.
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According to the researchers:
We examined each note for the number and percentage of manually entered, imported and copied characters. We used the non-parametric, 1-way Kruskal-Wallis test to examine differences between provider types. We performed data manipulations using the open source tool DB Browser for SQLite version 3.9.1, and we conducted the analysis using the free software R version 3.3.3 (R).
The results of the study show a clear inclination toward copied and imported text. In a typical EHR progress note, 46 percent of the text was copied and 36 percent was imported. A mere 18 percent was entered manually.
Among direct care hospitalists, 47.9 percent of the average note was copied, while 14.1 percent was manually entered. Residents copied more (51.4 percent) and manually entered less (11.8 percent) than direct care hospitalists. Medical students, meanwhile, copied 49 percent of the average note and manually entered 16.2 percent.
Additionally, the researchers uncovered that direct care hospitalists wrote shorter notes (5,006 characters) than residents (6,720 characters) and medical students (7,053 characters).
Photo: Ian Hooton, Getty Images
