Cloning Persistent Problem in EHR Data Entry

Amanda Guerrero
Twitter: @meanusenetwork

Moving patient health records from paper charts to a computerized format can improve care quality and result in better treatment outcomes. However, not all EHR software functions are better for patients’ health. According to a study by the Society of Critical Care Medicine, many doctors use copy/paste shortcuts to enter data into patients’ charts. The practice, known as cloning, speeds up the documentation process but often leads to outdated or incorrect data finding its way into patients’ health records.

For the study, researchers used plagiarism-detection software to examine progress notes completed by residents and attending physicians at a Cleveland medical center for 135 different intensive care unit patients. The following key findings were registered:

• Copy/paste was used by 82 percent of medical residents and 74 percent of attendings
• Copy/paste was used more than 20 percent of the time by both groups
• After a day off, copy/paste was used more often by attendings (94 percent) and less often by residents (66 percent)

Doctors often use keyboard shortcuts to save time when charting; however, doing so could result in medical errors and improper billing. This defeats one of the main purposes of an EHR, which is to create more accurate health records and improve the quality of patient care.

When erroneous data is continuously carried over from one progress note to the next, the medical record begins to lose clarity. This can be detrimental to patients’ health, particularly in intensive care settings where even small changes in treatment or medications could significantly change the patient’s outcome. Therefore, it is important for the data documented in the EHR to be accurate and up to date and not a copy of a previous note.

One way to reduce the use of cloning in healthcare settings is to properly train physicians on EHR best practices and to provide them with resources, such as voice recognition software, that facilitate documentation. Doing so will not only ensure the accuracy and integrity of patient health records – it can also help prevent medical errors and rejected medical claims down the line.

Amanda Guerrero is a content writer specializing in EHR, healthcare technology and Meaningful Use. In addition to maintaining her own health IT-related blog, she contributes to websites such as HealthTechnologyReview and HITECHAnswers.net.