Copy, Paste, and Cloned Notes in Electronic Health Records

Weis, Justin M.; Levy, Paul C.

doi:10.1378/chest.13-0886

Cited by 98 publications

(38 citation statements)

References 12 publications

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“…Many have documented current concerns with electronic documentation. 24,25 These concerns have been documented outside the United States where EHRs are used. 10,11 One study examined two potential avenues for improving documentation: having residents attend a lecture or having them attend a lecture coupled with individual feedback on notes.…”

Section: Discussionmentioning

confidence: 99%

“…This study also provides some confirmatory evidence to support concerns related to the negative impacts of autopopulated data and copy and pasted data in notes. 24,25 Not only did participants report frustrations and barriers due to auto-populated data and extraneous information, but moving this information to the end of the note decreased time spent reviewing note sets. This supports findings from other studies that indicate clinicians are generally more satisfied with notes in APSO order instead of SOAP.…”

Section: Discussionmentioning

confidence: 99%

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Challenges and Opportunities to Improve the Clinician Experience Reviewing Electronic Progress Notes

et al. 2019

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Background High-quality clinical notes are essential to effective clinical communication. However, electronic clinical notes are often long, difficult to review, and contain information that is potentially extraneous or out of date. Additionally, many clinicians write electronic clinical notes using customized templates, resulting in notes with significant variability in structure. There is a need to understand better how clinicians review electronic notes and how note structure variability may impact clinicians' note-reviewing experiences. Objective This article aims to understand how physicians review electronic clinical notes and what impact section order has on note-reviewing patterns. Materials and Methods We conducted an experiment utilizing an electronic health record (EHR) system prototype containing four anonymized patient cases, each composed of nine progress notes that were presented with note sections organized in different orders to different subjects (i.e., Subjective, Objective, Assessment, and Plan, Assessment, Plan, Subjective, and Objective, Subjective, Assessment, Objective, and Plan, and Mixed). Participants, who were mid-level residents and fellows, reviewed the cases and provided a brief summary after reviewing each case. Time-related data were collected and analyzed using descriptive statistics. Surveys were administered and interviews regarding experiences reviewing notes were collected and analyzed qualitatively. Results Qualitatively, participants reported challenges related to reviewing electronic clinical notes. Experimentally, time spent reviewing notes varied based on the note section organization. Consistency in note section organization improved performance (e.g., less scrolling and searching) compared with Mixed section organization when reviewing progress notes. Discussion Clinicians face significant challenges reviewing electronic clinical notes. Our findings support minimizing extraneous information in notes, removing information that can be found in other parts of the EHR, and standardizing the display and order of note sections to improve clinicians' note review experience. Conclusion Our findings support the need to improve EHR note design and presentation to support optimal note review patterns for clinicians.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Challenges and Opportunities to Improve the Clinician Experience Reviewing Electronic Progress Notes

et al. 2019

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“…Others acknowledged that this strategy requires a high level of vigilance to avoid introducing inaccuracies into the EHR. 4 Also, the extent to which some exam room computing could be accomplished without negatively affecting patient relationships allowed some to complete EHR tasks during the patient visit while others refrained from it completely. More research in this area is needed to develop and implement an approach that effectively integrates computer use into the exam room without diminishing patientcentered care and physician resilience.…”

Section: Discussionmentioning

confidence: 99%

The Thrill Is Gone: Burdensome Electronic Documentation Takes Its Toll on Physicians’ Time and Attention

et al. 2019

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“…Despite obvious advantages, the change to complete electronic documentation is a matter of ongoing discussion; on one hand, electronic documentation promises increased efficiency and improvements in patient treatment through availability and readability. On the other hand, there are concerns of exchanging information electronically, such as the tracking of data to an individual, general data security, or compliance with local regulatory requirements [ 4 ]. An insufficient adaptation of systems for specific clinical requirements (eg, in pediatrics) immediately reduces the clinical usefulness, leading to avoidance and thereby manifesting the status quo [ 17 ].…”

Section: Discussionmentioning

confidence: 99%

“…Clinical information can be lost due to insufficient adaptation and weighting of the inserted content. Besides, unforeseeable legal issues could be suspected [ 4 ].…”

Section: Introductionmentioning

confidence: 99%

Analysis of Documentation Speed Using Web-Based Medical Speech Recognition Technology: Randomized Controlled Trial

Vogel¹,

Kaisers²,

Waßmuth³

et al. 2015

J Med Internet Res

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BackgroundClinical documentation has undergone a change due to the usage of electronic health records. The core element is to capture clinical findings and document therapy electronically. Health care personnel spend a significant portion of their time on the computer. Alternatives to self-typing, such as speech recognition, are currently believed to increase documentation efficiency and quality, as well as satisfaction of health professionals while accomplishing clinical documentation, but few studies in this area have been published to date.ObjectiveThis study describes the effects of using a Web-based medical speech recognition system for clinical documentation in a university hospital on (1) documentation speed, (2) document length, and (3) physician satisfaction.MethodsReports of 28 physicians were randomized to be created with (intervention) or without (control) the assistance of a Web-based system of medical automatic speech recognition (ASR) in the German language. The documentation was entered into a browser’s text area and the time to complete the documentation including all necessary corrections, correction effort, number of characters, and mood of participant were stored in a database. The underlying time comprised text entering, text correction, and finalization of the documentation event. Participants self-assessed their moods on a scale of 1-3 (1=good, 2=moderate, 3=bad). Statistical analysis was done using permutation tests.ResultsThe number of clinical reports eligible for further analysis stood at 1455. Out of 1455 reports, 718 (49.35%) were assisted by ASR and 737 (50.65%) were not assisted by ASR. Average documentation speed without ASR was 173 (SD 101) characters per minute, while it was 217 (SD 120) characters per minute using ASR. The overall increase in documentation speed through Web-based ASR assistance was 26% (P=.04). Participants documented an average of 356 (SD 388) characters per report when not assisted by ASR and 649 (SD 561) characters per report when assisted by ASR. Participants' average mood rating was 1.3 (SD 0.6) using ASR assistance compared to 1.6 (SD 0.7) without ASR assistance (P<.001).ConclusionsWe conclude that medical documentation with the assistance of Web-based speech recognition leads to an increase in documentation speed, document length, and participant mood when compared to self-typing. Speech recognition is a meaningful and effective tool for the clinical documentation process.

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Copy, Paste, and Cloned Notes in Electronic Health Records

Cited by 98 publications

References 12 publications

Challenges and Opportunities to Improve the Clinician Experience Reviewing Electronic Progress Notes

Challenges and Opportunities to Improve the Clinician Experience Reviewing Electronic Progress Notes

The Thrill Is Gone: Burdensome Electronic Documentation Takes Its Toll on Physicians’ Time and Attention

Analysis of Documentation Speed Using Web-Based Medical Speech Recognition Technology: Randomized Controlled Trial

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