I recently took care of a patient whose medical records included multiple notes about her past open-heart surgery.
Only she had never undergone open-heart surgery.
That would have been obvious if the authors had taken the time to notice that she had no scars on her chest or breastbone. She was being prepared for an invasive procedure based on this misinformation when the true facts of her condition were revealed and the procedure canceled — though by then the false information had virally propagated through the chart and into multiple notes, becoming “chart lore.”
This event is hardly unique. Some years ago, a physician wrote a case study about a patient who went to the emergency room with chest pain. The patient’s chart showed a history of “PE,” so an ER physician ordered a CT scan to rule out recurrence of a “pulmonary embolism,” a blood clot in the lungs. However, the patient denied ever having had a pulmonary embolism. Further investigation showed that the letters “PE” referred to physical examination. The misdiagnosis had been entered into the medical history nearly a decade earlier and had been copied forward ever since.
Electronic copying and pasting has become a major problem in health care. A recent study of 100 million notes, consisting of 33 billion words, in the electronic medical record at the University of Pennsylvania Medical Center found that more than half of the text was duplicated. This copied-and-pasted content was prevalent in notes written by everyone from nurses and therapists to physicians at all levels of training.
“Finding the right information is no longer a matter of flipping through a paper chart,” the study’s authors wrote. “It is more akin to reading large portions of a book.”
From 2009 to 2018, as electronic medical records became ubiquitous, chart notes doubled in length. In the Penn study, the average patient record had more than half the word count of Shakespeare’s “Hamlet.” The majority of that content was copied and pasted, word for word.
With the computerization of medical notes, health care providers can now easily copy and manipulate large swaths of previously documented information. Surveys show that most health care providers admit to using copy and paste functions when writing clinical notes. For instance, physicians frequently copy medical histories obtained by other physicians or chart notes from prior hospitalizations. Such cribbing is encouraged by the current medical billing system, in which chart documentation is used not only for clinical but also legal and financial purposes. Notes are dissected by billing agents to maximize hospital revenue. More details, even irrelevant ones, often result in more money. Adding more diagnoses to a chart note, for example, even if extraneous, may make a patient look sicker and garner more payments.
The resulting redundancy often obscures important information — the proverbial needle-in-a-haystack problem. Indeed, today’s chart notes, filled with unnecessary and often copied details, are causing physicians to make diagnostic errors. “Overworked clinicians may be disincentivized from reading such a bloated record,” the authors of the Penn study wrote in obvious understatement, adding that this can lead to “wasted time repeating past interventions or directly causing patient harm by missing findings requiring follow-up.”
Moreover, content is being copied without confirming the accuracy of the information being duplicated. In a 2017 study of approximately 24,000 notes written by 460 clinicians at University of California San Francisco Medical Center, more than 80 percent of the text was copied or imported from a previous document. This practice, the authors wrote, “increases the risk of including outdated, inaccurate or unnecessary information, which can undermine the utility of notes and lead to a clinical error.”
None of this should come as any great surprise: Information overload and frank misinformation are defining features of our digital lives. However, the effects on the profession of medicine should be of great concern.
The amount of information generated in a typical physician-patient encounter has always been voluminous. In a survey published in 2013 of nearly 2,600 primary care physicians, 70 percent reported receiving more information — lab tests, imaging studies, and written assessments — than they could manage.
But with the advent of electronic medical charts and the rampant use of copying and pasting, information overload and errors have multiplied. I dare say that doctors were more diligent about the accuracy of their notes when they were written freehand in paper charts. Text could not be copied and pasted. Today, information is readily archived and manipulated, propagating mistakes.
Even when the information is technically accurate, notes today often rehash events that have already occurred or problems that have already been resolved. This wastes time and impairs decision-making. Adding minute details about a patient’s prior hospitalizations often only confuses the problem at hand.
In addition, a narrative element is often missing in medical charts today, as chunks of information are pasted haphazardly into notes. Narratives humanize patients, who, despite what modern electronic medical records may suggest, are not disconnected lists of copied and pasted facts.
No doubt, electronic medical records have produced great benefits, too. Doctors can now access patients’ information virtually anywhere (though this may also be contributing to widespread clinician burnout). Computerized order entry reduces medication errors.
However, we must get smarter about how we use the power of electronic charts. First, hospitals need to design a system that encourages the documentation of truly novel (and accurate) information. Relatively stable patient information should be stored separately and not be repeated in daily notes, contributing to bloat. This will require a change in how physician-patient interactions are billed so that long notes that include irrelevant details are not monetarily rewarded.
Furthermore, as the authors of the Penn study argue, some duplication may be eliminated by having a single daily progress note that multiple physicians can add to and edit. Hospitals may also consider restricting the use of copying and pasting. At the very least, copied-and-pasted material should be readily identifiable so it can be checked for accuracy.
Despite the benefits of electronic medical records, in many ways they are being outweighed by the risks associated with redundant and inaccurate notes. We call out health misinformation when it is generated on social media, but the biggest and most serious source of health misinformation today may be the medical chart itself.
Sandeep Jauhar, a doctor at Northwell Health in New York, is the author, most recently, of “My Father’s Brain: Life in the Shadow of Alzheimer’s,” which was published in April.