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

Edward Winslow edbjwinslow at GMAIL.COM
Wed Oct 26 16:23:43 UTC 2016


Couldn't agree more.

On Oct 24, 2016 5:03 PM, "Elias Peter" <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> 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 <914-522-2116>*
>
> *Sent from my iPhone*
>
>
>
> On Oct 23, 2016, at 1:38 PM, robert bell <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> 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
> 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> 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>
> 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>
> 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>
> *Sent:* Saturday, October 22, 2016 1:16:14 AM
> *To:* IMPROVEDX at LIST. IMPROVEDIAGNOSIS.ORG
> <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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