Electronic medical records (EMRs) have been in use for more than 30 years, but have only increased in utilization in recent years, due in part to research supporting the benefits of EMRs and federal legislation.
As EMRs have become a standard in medical care, there is a need for additional research of how the system and usage can be refined.
A group of researchers from Brigham and Women's Hospital have done just that, and discovered that one way false information can make its way into EMRs is due to users' reliance on copying and pasting material within the patient's record. These findings are published in the May 23 issue of Archives of Internal Medicine.
"Previous research has shown that copying and pasting fragments of notes is common in EMRs. However, it was not known whether the resulting information was accurate," said Alexander Turchin, MD, a physician in the Endocrine Division at BWH and a Senior Medical Informatician at Partners HealthCare. "Our study is the first to show in a systematic way that the copy-and-pasted material may not be accurate."
The researchers studied the EMRs of 5,914 diabetic adults being cared for by primary care physicians. They used specially designed software to track copied records of lifestyle counseling documentation in these patients' EMRs.
By comparing average blood glucose levels between patients with and without copied EMR records, they found that copied lifestyle counseling documentation was not associated with improvements in glucose control, similar to having received no counseling at all.
"Our research has unveiled some potential negative ramifications of copying and pasting documentation in EMRs," said Dr. Turchin, who explains the next steps include educating health care providers about this issue, and investigating ways to prevent copying and pasting by providing a helpful alternative.
Source: Archives of Internal Medicine
