RESUMEN
Electronic patient records often include text that has been copied and pasted from other records. A type of copying that involves the highest risk for confusion, medical error, and medico-legal harm is the copying of the clinical examination. We studied this phenomenon using an automated text categorization algorithm to detect copied exams in a set of 167,076 VA records. Exam copying occurred frequently, in about 3% of all exams, or in 25% of patient charts. Thirteen percent of all authors had copied at least one exam, and 3% of authors had copied an exam from another author. There were significant differences between service types and levels of training of the authors. We speculate that copying and pasting of exams degrades the quality of the medical record, and that studying this behavior is integral to our understanding of phenomenology of the electronic medical record.
Asunto(s)
Gestión de la Información/normas , Sistemas de Registros Médicos Computarizados , Examen Físico , Interfaz Usuario-Computador , Algoritmos , Auditoría MédicaRESUMEN
Across the country, new RHIOs are being formed every day. The 21 RHIOs studied by the work group illustrate the variety of purposes, funding, and record linking methods RHIOs may adopt. As this trend continues to evolve and improve, RHIOs may prove to be a valuable stepping stone on the road to a national system in which a patient's medical data will be available anywhere, anytime. Accurate patient identification and linking are the foundation of health technology that is implemented in a RHIO or any similar network that shares patient information. Without accurate patient identification, patient safety and quality of care are compromised. When high percentages of duplication or overlaying of records occurs in electronic health record databases, physician trust in the system is lost. As HIM professionals, we must be involved in addressing the security and confidentiality of RHIO databases and in defining the record linking method appropriate to the RHIO. As professionals skilled in patient identification methods and possessing significant organizational skills and personnel management experience, HIM professionals should become involved in this process at the earliest opportunity in the RHIO formation. HIM professionals can participate in long-term planning, business plan development, and organizational structure definition. Future articles will address how HIM professionals can become involved, what particular attributes and skills they can bring to the table, and job descriptions appropriate to HIM professionals in the healthcare information sharing industry. The work group urges all HIM professionals to become involved personally in this exciting new field.
Asunto(s)
Registro Médico Coordinado/métodos , Sistemas de Identificación de Pacientes , Humanos , Informática Médica/organización & administración , Estados UnidosAsunto(s)
Gestión de la Información/tendencias , Administradores de Registros Médicos/psicología , Innovación Organizacional , Adaptación Psicológica , Humanos , Gestión de la Información/organización & administración , Administradores de Registros Médicos/organización & administración , Estados UnidosRESUMEN
As routine use of on-line progress notes in US Department of Veterans Affairs facilities grew rapidly in the past decade, health information managers and clinicians began to notice that authors sometimes copied text from old notes into new notes. Other sources of duplication were document templates that inserted boilerplate text or patient data into notes. Word-processing and templates aided the transition to electronic notes, but enabled author copying and sometimes led to lengthy, hard-to-read records stuffed with data already available on-line. Investigators at a VA center recognized for pioneering a fully electronic record system analyzed author copying and template-generated duplication with adapted plagiarism-detection software. Nine percent of progress notes studied contained copied or duplicated text. Most copying and duplication was benign, but some introduced misleading errors into the record and some seemed possibly unethical or potentially unsafe. High-risk author copying occurred once for every 720 notes, but one in ten electronic charts contained an instance of high-risk copying. Careless copying threatens the integrity of on-line records. Clear policies, practitioner consciousness-raising and development of effective monitoring procedures are recommended to protect the value of electronic patient records.