[Spam] Re: [IMPROVEDX] The Dangers of Copy and Paste in the EHR

rkoppel rkoppel at SAS.UPENN.EDU
Tue Oct 25 02:26:57 UTC 2016


As probably the only one on this list who has taught social research methods (in part questionnaire construction) for the past 40 years, I agree so much with the previous comments about those terrible questionnaires.    I had to fill our one for my 16 year old son when getting his wisdom teeth extracted.  The questionnaire asked if the patient's  teeth hurt more when having a period.  I decided that if he were to have a period, his teeth would be the last thing he's worry about.




Ross Koppel, PhD, FACMI

UNIVERSITY OF PENNSYLVANIA

Sociology Dept;  LDI Senior Fellow, Wharton; &

Affil Fac. Sch. of Medicine.

Chair, AMIA Clinical Information Systems Working Group.

Ph: 215 576 8221; Cell 215 518 0134



________________________________
From: Elias Peter <pheski69 at GMAIL.COM>
Sent: Monday, October 24, 2016 8:56 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] [Spam] Re: [IMPROVEDX] The Dangers of Copy and Paste in the EHR

I hate those questionnaires. I hate them when I have to fill them out for myself or for family members,  and I hate them when I have to review them. Sadly, they have become a fixture in medicine.  I have this fantasy that we could have a system where a ‘facilitated history’ is developed during a conversation between the patient (and family if the patient is willing) and a trained clinical history taker. This would be comprehensive but relate to past events, not the current issues, which really need an active conversation with the clinical care team rather than a data collection system. This facilitated history, once collected, should then be something the patient has control of and can provide in part or full to members of the care team. It would need to be editable in the sense of adding new information or correcting errors, but would be relatively static.

I cannot imagine holding a patient responsible for errors in the record unless/until the patient is allowed to generated/maintain the record. Even then, I have misgivings. I do not want to be held liable for errors in the way I describe malfunctions in my furnace to the repairman. If I willfully deceive the repairman (or my clinician) the repairman (or clinician) should not be liable for acting on my deceptive information.

Peter


On 2016.10.24, at 6:46 PM, HM Epstein <hmepstein at GMAIL.COM<mailto:hmepstein at GMAIL.COM>> wrote:

Dear Peter:
I wish you were my physician. Any plans to move to NYC?

When I referred to questions in my response to Rob, I meant the patient's history as filled out on 10 pages of badly photocopied sheets on a clipboard with too little space for any details  (in some offices replaced by a clumsy computer tablet) and with a long list of questions the patient has to answer. History of illness and surgeries, family history, current medications, allergies - medicine and environmental and foods, and so on. This is the data that should end up in the EHR along with the examination notes, test results, etc.

I was reacting to his suggestion that the patient or their designee (or mommy) can be held liable for errors on that document. I think that's untenable until filling out those forms becomes less onerous. I don't know how many young moms juggling two kids or elderly patients struggling to read the small broken type I've seen sigh and shake their heads and give up.

I had suggested to my Ob/Gyn that her patient history forms should include a few missing questions. One example was to ask if the patient had any new or recent GI symptoms, since those may be the only warning signs of ovarian cancer that ever show. (A close friend is dying, stage 4, which was discovered only because she was in so much pain, she thought it was her appendix and went to the ED. However, she had seen her Gyn regularly and had been experiencing relevant GI symptoms for a year. No one asked her, so she never thought to mention it to her Gyn.)

With most of my physicians, they will ask questions while examining me and after. However, the patient shouldn't be liable for errors in that situation either. Communication doesn't happen until one person understands the other and then responds. Hopefully without one hand on the doorknob or one's head in the laptop.

Best,
Helene

hmepstein.com<http://hmepstein.com/>
@hmepstein<https://twitter.com/hmepstein>
Mobile: 914-522-2116

On Mon, Oct 24, 2016 at 4:47 PM, Elias Peter <pheski69 at gmail.com<mailto:pheski69 at gmail.com>> wrote:
I was trained to believe that questions come at the very end of the process of learning the patient’s history. Any history developed primarily by a Q & A process is tremendously at risk for being driven by the clinician’s frame, not the patient’s frame. Once this has happened, it is very hard to upright the bell. Here is what I was taught:


  *   One starts with an open-ended question, such as: “Let’s start by having you tell me what’s been going on and what your concerns are.”
  *   Then the patient is allowed to tell his-story or her-story until they reach the end, with minimal prompting and preferably no interruptions. Good ‘prompts’ are ‘Mmm’ and ‘I see’ and ‘And then?’
  *   Only when that process is done, is it time to ask questions: "Thanks. Now I need to ask come questions to clarify things or fill in some details. Let me know if you don’t understand the question or why I am asking.”

The computer-centric EHR did not exist back then. Several years ago I began encouraging patients to see what I am typing while I am typing, and giving them a copy of the note at the end of the visit.

Peter Elias


On 2016.10.24, at 4:28 PM, HM Epstein <hmepstein at GMAIL.COM<mailto:hmepstein at GMAIL.COM>> wrote:

Hi Rob:
You asked if the patient or the patient's designee should be legally responsible for their part of the history. IMO that's legally and morally untenable because the patient is only going to answer the questions they've been asked or share what they think is key.

First, the questions have to be relevant. I just went in to see an OB/GYN, for an annual check up. It was my first time visiting the practice. I answered all of the questions to the best of my knowledge but when I met the physician, I informed her that there were several questions she should've asked and didn't. We had an interesting discussion and I ended up getting a more thorough exam and series of tests than I might have. But I am a patient and the parent of a patient who have both been multiply misdiagnosed, and several times with severe consequences, so I've been educated in the worst way possible. The majority of Americans have not been through that same trial.

 Additionally, you can't hold a patient responsible for an incomplete or inaccurate history when the amount of time the patients get with their physicians has been shrinking steadily to the medical equivalent of a tweet. I'm not able to check my database but I recall hearing that the average patient is given only 90 seconds to explain why they're there before they're interrupted by the doctor and that a hospitalized patient gets only eight minutes with the attending. So, how are they supposed to tell the full story of a prolonged diagnostic journey? They may not even know it's been a prolonged diagnostic journey because they've accepted the partial or incorrect diagnosis they have been given before.

Plus patients suffer all of the same cognitive errors that doctors are prone to and they've made the incorrect data part of their medical history. I don't know how many physicians I told that my son was suffering from PANDAS -- which was incorrect but was what he was being treated for. I prepared the ground for an anchoring bias thinking I was being helpful in providing what I considered to be key information. I was wrong, of course. But I was also tired of my son being misdiagnosed with growing pains and allergies when he was profoundly ill and getting worse. I hear this again and again and again from family is a pediatric patients I've interviewed.

I would rather a patient say to the physician, "Here are my symptoms and the reasons I'm coming in, here are my current medications and Rx allergies, my birthdate, and that's all I can share with you. Figure the rest of it out." I also would prefer every physician assume that the medical history in front of them has inconsistencies and inaccuracies that need to be investigated. I think we might end up with better results. Perhaps with the reimbursement changes in Medicare and Medicaid, we're getting closer to that happening.

Best,
Helene

--
hmepstein.com<http://hmepstein.com/>
@hmepstein
Mobile: 914-522-2116<tel:914-522-2116>

Sent from my iPhone



On Oct 23, 2016, at 1:38 PM, robert bell <0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG<mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>> wrote:

Very good point William.

Should the Physician, HCP, Consultant, Patient or Patient’s designee be legally responsible for their part of the accuracy of the information in the EMR?

Would that help move towards greater accuracy?

Rob
On Oct 23, 2016, at 4:42 AM, DR WILLIAM CORCORAN <williamcorcoran at sbcglobal.net<mailto:williamcorcoran at sbcglobal.net>> wrote:

Minor Issue

It is only after the harmful events that they are involved in can you tell that errors, anomalies, deviations, changes, and differences were minor.

Take care,

Bill Corcoran


William  R. Corcoran, Ph.D., P.E.
21 Broadleaf Circle
Windsor, CT 06095-1634
860-285-8779<tel:860-285-8779>
William.R.Corcoran at 1959.USNA.com<mailto:William.R.Corcoran at 1959.USNA.com>
http://www.linkedin.com/in/williamcorcoranphdpe
https://www.box.com/shared/kfxg1lt9dh



On Saturday, October 22, 2016 8:26 PM, robert bell <0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG<mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG>> wrote:


How frequently does a patient’s history/story change?

How frequently does a patient give the wrong history and relevant information?

it seems that some level of error must be accepted but it also seems that we should attempt to reduce as much error as we can.

And patient involvement should be encouraged to facilitate that.

Rob Bell


On Oct 22, 2016, at 11:29 AM, Peggy Zuckerman <peggyzuckerman at GMAIL.COM<mailto:peggyzuckerman at GMAIL.COM>> wrote:

Part of the issue which must be considered, whether in a cut and paste situation, or in the retrieval and use of any record, is that there are likely errors which could be corrected by the patient, and rarely is that permitted.

There is the issue beyond that in which those corrections, whether from patient or physician, are not broad-reaching, such that another doctor/institution using their version of the record does not those corrections.  And there may be errors as to basic identity in up to 15% of records.  The misidentified patient may be treated multiple times, with those additions further affecting that record.  Naturally the 'real' patient who then is properly identified with that record is now confused with the misidentified patient.

Peggy Zuckerman

Peggy Zuckerman
www.peggyRCC.com<http://www.peggyrcc.com/>

On Sat, Oct 22, 2016 at 6:25 AM, Swerlick, Robert A <rswerli at emory.edu<mailto:rswerli at emory.edu>> wrote:
I believe the cut and past phenomena and the concerns raised miss an important point. When a patient is seen over time, what information MUST be carried forward in order to manage the patient? I certainly should not be in a position where when I see a patient back I walk in the room totally ignorant of their history and course other than what I remember from recall.

What information should ALWAYS be carried forward and where should this reside within the record. Cut and paste is a convenient but flawed approach to a real problem which does not have a tool within EHR's which allows for ready access to information we should all have when we have a encounter and are called upon to make clinical decisions.

Before we condemn the cut and paste practice wholesale, we need to consider what alternatives exist to replace the functions it fulfills.

Robert A. Swerlick, MD
Alicia Leizman Stonecipher Chair of Dermatology
Professor and Chairman, Department of Dermatology
Emory University School of Medicine
404-727-3669
________________________________
From: HM Epstein <hmepstein at GMAIL.COM<mailto:hmepstein at GMAIL.COM>>
Sent: Saturday, October 22, 2016 1:16:14 AM
To: IMPROVEDX at LIST. IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: [IMPROVEDX] The Dangers of Copy and Paste in the EHR

 I was surprised by this report from ECRI. They did a retrospective look at EHRs and found only 7.4% used cut-and-paste. However, of that small sample, 36% of the cut-and-paste entries contributed to Dx error.

Based on all of the complaints I've read about cut-and-paste use in EHRs, I truly expected to see that the incidence was much higher. Has anyone seen other studies to compare to this? Does it accurately reflect your expectations from your own observations in your place of work?

Thank you.

Best,
Helene

http://www.diagnosticimaging. com/ehr/dangers-copy-and- paste-ehr<http://www.diagnosticimaging.com/ehr/dangers-copy-and-paste-ehr>

The Dangers of Copy and Paste in the EHR
October 21, 2016
By Erica Sprey<http://www.diagnosticimaging.com/authors/erica-sprey>
By nature of design, EHR systems encourage physician users to copy old patient data, like medication lists and chronic conditions, and copy and paste the information into the current note. In doing so there are benefits and risks for both physicians and patients, according to Lorraine Possanza, DPM, JD, and Robert Giannini, NHA, of the nonprofit ECRI Institute<https://www.ecri.org/Pages/default.aspx>. Possanza and Giannini were co-presenters at the American Health Information Management Association's (AHIMA<http://www.ahima.org/>) annual conference in Baltimore, Md., held on Oct. 17, speaking on "Safe Practices for Copy and Paste."
The ECRI Institute's mission is to provide physicians and other health professionals evidence-based guidelines on the most effective medical procedures, devices, and drugs, via scientific research. In order to understand the affect that potentially unsafe practices like "copy and paste" have on patient safety, ECRI applies a three-prong approach, says Possanza. This includes data collection; data analytics; and leveraged learning that reaches out to both EHR vendors and medical staff.
While reporting can seem onerous to overworked staff, it is vital to understand the extent of the problem. Possanza provided conference attendees an example where copy and paste can hinder the physician and her staff as she treats a hospitalized patient who suffers from pressure ulcers. If the initial assessment is copied and pasted forward in the note on subsequent patient visits, the physician does not have a true picture of the progression of the ulcers and may not trust the validity of the information in the note.
Copy and paste also contributes to "note bloat" says Possanza, making it difficult for a physician to pick out pertinent information that is swallowed up by redundant information. It is vital that patient information is accurate, timely, and easily assessable she says, adding that a dense note can contribute to diagnostic error.
The ECRI Institute did a retrospective study on diagnostic error that found 7.4 percent of audited charts contained copy and paste information, and of that group, 36 percent contributed to diagnostic error. "How does copy and paste influence [diagnostic error]? Through note bloat, through those internal inconsistencies, through the propagation of errors," says Possanza. "If I pasted information and it's incorrect and I repeatedly paste that information that is incorrect, I now have errors that are propagated."
In order to minimize the chances of error, Possanza says physicians and other clinicians must be accurate in their notes, concisely document the patient information, attribute where copy and paste material came from, and give context where appropriate.
It is essential that physicians and other medical staff feel that they can report health information technology (HIT) related-errors in a non-punitive environment, so that management can address any systemic problems. And it is also equally important that staff are trained on copy and paste best practices. To that end, the Partnership for HIT Patient Safety<https://www.ecri.org/resource-center/Pages/HITPartnership.aspx> has released the first "Health IT Safe Practices: Toolkit for the Safe Use of Copy and Paste,"<https://www.ecri.org/Resources/HIT/CP_Toolkit/Toolkit_CopyPaste_final.pdf> which examines the scope of the problem, defines the various stakeholders and provides safe-practice guidelines for providers.
The Partnership has developed four recommendations for providers and their staff, says Possanza:
A: Provide a mechanism to make copy and paste material easily identifiable;
B: Ensure that the provenance (and chronology) of copy and paste material is readily available;
C: Ensure adequate staff training and education regarding the appropriate and safe use of copy and paste; and
D: Ensure that copy and paste practices are regularly monitored, measured, and assessed.




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