Physicians’ Attitudes Towards Copy and Pasting in Electronic Note Writing

O’Donnell, Heather; Kaushal, Rainu; Barrón, Yolanda; Callahan, Mark; Adelman, Ronald D.; Siegler, Eugenia L.

doi:10.1007/s11606-008-0843-2

Cited by 93 publications

(86 citation statements)

References 24 publications

(24 reference statements)

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“…In our EHR, these data are automatically imported into the ED physician note. Studies have cautioned against too much copy and paste data and standard text that masks the pertinent information [30,31].Another approach is to better understand and embrace these data sharing and integration workflows and then design the EHR to better support these workflows. For instance, a dashboard could be created to support the "chart biopsy, " providing a single screen summarizing key clinical data for ED patients [32,33].…”

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confidence: 99%

Emergency Medicine Resident Physicians’ Perceptions of Electronic Documentation and Workflow

Neri¹,

Redden²,

Poole³

et al. 2015

Appl Clin Inform

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SummaryObjective: To understand emergency department (ED) physicians' use of electronic documentation in order to identify usability and workflow considerations for the design of future ED information system (EDIS) physician documentation modules. Methods: We invited emergency medicine resident physicians to participate in a mixed methods study using task analysis and qualitative interviews. Participants completed a simulated, standardized patient encounter in a medical simulation center while documenting in the test environment of a currently used EDIS. We recorded the time on task, type and sequence of tasks performed by the participants (including tasks performed in parallel). We then conducted semi-structured interviews with each participant. We analyzed these qualitative data using the constant comparative method to generate themes. Results: Eight resident physicians participated. The simulation session averaged 17 minutes and participants spent 11 minutes on average on tasks that included electronic documentation. Participants performed tasks in parallel, such as history taking and electronic documentation. Five of the 8 participants performed a similar workflow sequence during the first part of the session while the remaining three used different workflows. Three themes characterize electronic documentation: (1) physicians report that location and timing of documentation varies based on patient acuity and workload, (2) physicians report a need for features that support improved efficiency; and (3) physicians like viewing available patient data but struggle with integration of the EDIS with other information sources. Conclusion: We confirmed that physicians spend much of their time on documentation (65%) during an ED patient visit. Further, we found that resident physicians did not all use the same workflow and approach even when presented with an identical standardized patient scenario. Future EHR design should consider these varied workflows while trying to optimize efficiency, such as improving integration of clinical data. These findings should be tested quantitatively in a larger, representative study. Research Article P.M. Neri et al.: Physicians' Perceptions of Electronic Documentation and WorkflowFor personal or educational use only. No other uses without permission. All rights reserved. BackgroundElectronic clinical documentation serves multiple purposes including communication, billing, maintenance of a legal record, and serves as a tool for synthesis and medical decision making. Electronic Health Record (EHR) incentive programs in the United States designed to stimulate health information technology (HIT) adoption require hospitals and providers to show they use the EHR "meaningfully" and meet certain objectives in order to receive incentive payments. The second stage of the meaningful use program recognizes the importance of electronic documentation by including it as a menu objective to fulfill program requirements [1]. In response to these policies and incentives, emergency departments (EDs)...

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mentioning

confidence: 99%

Emergency Medicine Resident Physicians’ Perceptions of Electronic Documentation and Workflow

Neri¹,

Redden²,

Poole³

et al. 2015

Appl Clin Inform

View full text Add to dashboard Cite

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“…Our results are high compared to previous studies [13]. One factor that might be contributing to this is the setting of our research, which only analyzed notes written by residents, compared to other studies, which also included attending physicians.…”

Section: Discussionmentioning

confidence: 61%

“…Implementation of EMR has led to an increase in the time spent completing notes, resulting in an increased use of the copy-and-paste function by physicians [13,14]. The last few years have seen an increased interest in the evaluation of EMR.…”

Section: Introductionmentioning

confidence: 99%

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Use of dictation as a tool to decrease documentation errors in electronic health records

Hadidi

Upadhaya

Shastri

et al. 2017

Journal of Community Hospital Internal Medicine Perspectives

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Background: Use of Electronic Health Records is increasing. Copy-and-paste function is frequently used with higher rates of documentation errors. Studies to determine the nature of such errors are needed.Objectives: Determination of the effect of implementing a dictation system for completing notes on the quality of clinical documentation. We hypothesized that implementation of the dictation system for note writing would decrease the rate of errors in the progress notes as well as decrease the rate of copying and pasting. Design/Methods: A prospective interventional study in inpatient medical service for six months’ duration starting in July 2016. Resident physicians’ charts were reviewed by the attending physician on a daily basis. This study was done in a community based hospital affiliated to a university program. Residents’ physicians included Internal Medicine, Transitional year and Combined Internal Medicine Pediatrics residents. Charts reviewed for hospitalized patients. A total of 54 residents were offered a pre-intervention survey indicating their subjective use of copy/paste function. Response rate of 85.18%. Progress notes were reviewed on a daily basis for residents on their inpatient rotation. A total of 621 notes were reviewed. Results: Percentage of notes copied prior to the intervention was 92.73% which decreased to 49.71% post-intervention (RR of 0.54, 95% CI 0.48 0.60 Z statistic 11.005 with p-value <0.0001). Of the copied notes percentage of errors pre-intervention was 58% with no errors identified post-intervention (RR of 0.005, 95% CI 0.0003 0.0795 Z statistic 3.752 with p-value 0.0002). Most of the errors are from notes copied by the same author (85.8%). The most common documentation error was in the physical examination section. Conclusion: Implementing a dictation system eliminated documentation errors over our six months’ study. Further studies are needed to check long effects of using such systems on documentation errors

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“…Several studies have researched this copy and paste function. In fact, the copy and paste function has been considered a serious problem with the use of EMRs 3, 4, 5…”

Section: Introductionmentioning

confidence: 99%

Better documentation in electronic medical records would lead to an increased use of lower extremity venous ultrasound in the inpatient setting: a retrospective study

Takechi

Dote

Kim

et al. 2017

Acute Medicine & Surgery

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AimWe hypothesized that the quality of the assessment of abnormal laboratory data in the emergency department (ED) could affect the hospital‐attending physicians’ decision‐making after a patient's hospitalization. To test this hypothesis, we investigated how patients with a positive D‐dimer result were reported by ED physicians in electronic medical records, and measured whether lower extremity venous ultrasonography examination was undertaken during hospitalization by the hospital‐attending physicians.MethodsIn an urban tertiary acute care general hospital in Japan, between January 2012 and December 2013, we included patients hospitalized after a positive D‐dimer measurement (≥1.0 μg/mL) that was taken in the emergency department. We retrospectively measured the quality of ED physician assessments. Then we examined whether that affected the decisions of attending physicians to order lower extremity venous ultrasonography examinations during hospitalization. The exposure variable was the quality of the ED physicians’ assessment of patients with positive D‐dimer results. The outcome was whether a lower extremity venous ultrasonography examination was ordered by the attending physician during hospitalization.ResultsWhen assessments were described by ED physicians for patients with positive D‐dimer results, the attending physicians frequently ordered lower extremity venous ultrasonography (odds ratio, 10.74; 95% confidence interval, 5.92–19.50), even if the assessments only contained “copied and pasted” laboratory data (odds ratio, 1.68; 95% confidence interval, 2.10–2.40).ConclusionsBetter documentation by ED physicians, regarding patients with positive D‐dimer results, strongly affected the decisions made by attending physicians to order lower extremity venous ultrasonography examination.

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Physicians’ Attitudes Towards Copy and Pasting in Electronic Note Writing

Cited by 93 publications

References 24 publications

Emergency Medicine Resident Physicians’ Perceptions of Electronic Documentation and Workflow

Emergency Medicine Resident Physicians’ Perceptions of Electronic Documentation and Workflow

Use of dictation as a tool to decrease documentation errors in electronic health records

Better documentation in electronic medical records would lead to an increased use of lower extremity venous ultrasound in the inpatient setting: a retrospective study

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