When reviewing a patient’s history, a physician might be faced with pages upon pages of previously added clinical notes. By some estimates, the typical patient note is 4,000 characters—roughly 1.5 pages—and those add up over time.
Memories of those overstuffed medical records weighed on Rep. Dr. Phil Roe (R-Tenn.) during a congressional hearing this past summer, while questioning leaders from the Defense and Veterans Affairs departments on whether they were adequately engaging physicians in the implementation of their co-developed electronic health record system.
During the hearing, Roe recalled frustrations he ran into while practicing as a doctor and working with exceedingly lengthy patient notes in the EHR.
Though there are many reasons for long-winded documentation, Roe pointed a finger at two seemingly small computer commands that he felt had complicated his time as a doctor: Control-C and Control-V.
Copy-and-paste, two simple computer shortcuts, might not seem like a major concern for healthcare organizations, but in practice they can lead to loads of employee frustration and possible clinical errors.
“I saw it; it’s an experience I had,” Roe said during an interview with Modern Healthcare. Overuse of copy-and-paste would lead to lengthy patient records—sometimes leaving him to dig through 10 or so pages of information to find useful patient data. Other times, it meant getting patient notes from a referring physician, only to realize an error had been repeated throughout the record for months, if not years.
With copy-and-paste, “if you don’t read that whole thing, that misinformation stays in there,” he said. That can be true for something as simple as mixing up whether a patient is referencing a condition on their left or right side. If that information’s added to the record incorrectly, it could be copied-and-pasted for “two or three or four visits, just compounding an error that’s already in there,” Roe said.
Copying-and-pasting information like medical histories and discharge summaries from previous patient notes is just one of the many so-called “workarounds” clinicians have employed to save time while documenting in the EHR.