Turning medical residents away from copy-and-paste culture

Dr. Sarah Augustine

CLEVELAND, Ohio — A local medical center is trying to cut out the burgeoning subculture of “copy-and-paste”: A phenomenon made possible by electronic medical records in which physicians copy old information about a patient and paste it into a new section of the chart.

The practice is seen by medical residents as a time-saver, said Dr. Sarah Augustine, associate chief of medicine at the Louis Stokes Cleveland VA Medical Center. But she–and others in medicine–consider it an “egregious problem” because the practice has the potential to perpetuate mistakes. For example, someone might copy and paste information from a patient’s medical history without verifying that the information is correct. Any errors that might exist will be repeated.

Augustine and her colleagues can’t just disable the copy-and-paste function, since such a move would impact other programs. Nor do they want to take a punitive approach. So the VA’s Chief of Medicine Dr. Louis Rice thought of an incentive program that involves auditing the interns, or first-year residents, who do internal medicine rotations.

The program, which is just a few months old, requires interns to turn in a series of four consecutive notes about one patient. The notes are reviewed and scored by two evaluators who are either program directors or key clinical faculty. The interns then receive feedback about their note-taking skills.

The resident with the highest score is rewarded with a $25 gift certificate to a movie theater.

The goal is not just to get the interns to resist the urge to copy and paste.

“We want to try to teach them how you actually write a good note,” Augustine said. “We try to get them to think critically about what’s actually happened with the patient over the past 24 hours.”

Dr. Emaculate Tebit, an intern, said her notes have improved as a result of the VA’s incentive program. In fact, she earned the highest score during her second rotation at the VA. She has learned how to write shorter notes, to comment on patients’ lab results, to state the reasons why one diagnosis is more likely than another and to come up with a plan of care.

“We were given examples of good notes and examples of bad notes,” Tebit said in an e-mail. “I have been following the examples of good notes and that has helped me a lot.”

The VA has used electronic medical records for a long time, but the copy-and-paste phenomenon is not unique to the system, Augustine said.

“I see this being a problem everywhere,” she said.

Indeed, medical journals have devoted quite a bit of space to the issue in recent years. In June 2009, The American Journal of Medicine published an article that noted “the copy-and-paste function has led to a number of unexpected problems and concerns about electronic note writing and its impact on the culture of medicine, including reducing the credibility of the recorded findings, clouding clinical thinking, limiting proper coding and robbing the chart of its narrative flow and function.”

[Front cover image courtesy of Flickr user Robert S. Donovan]