E-Record Shortcuts Threaten Integrity of Medical Records

Medical records are supposed to be a truthful repository in real time of everything that happened to a patient. Their integrity is vital to high-quality patient care and to the ability of a patient to hold providers accountable in court if things go wrong. So word of widespread abuse of shortcuts allowed by electronic record systems is important for patients, lawyers and safety advocates.

A recent op-ed piece in the New York Times by Dr. Leora Horwitz, an assistant medical professor at Yale, documented problems like copy-and-paste where one provider’s error early in a patient’s treatment gets replicated over and over by later providers who are supposed to be recording their own independent observations of the patient.

Another issue is the too-tempting way that an e-system can allow a single mouse click to populate every box of a fill-in-the-blank physical examination with completely normal, healthy results.

Now more doctors have weighed in with letters to the Times editor on e-record abuses. One, Madhura Pradhan, a pediatric kidney specialist in Philadelphia, wrote:

The ease of using built-in shortcuts for documentation in medical records is teaching younger physicians to be efficient at the expense of being thorough.

Time and again, I see notes in charts that have clearly been copied or have been entered from standardized templates with conflicting information cited elsewhere in the chart. This not only compromises the patient-physician interaction but also makes me question the level of engagement of the physician in that visit.

Another, an internist in New York named George Lombardi, wrote: “It is deeply disrespectful and against a physician’s canon of ethics to take shortcuts in evaluating and caring for patients.”

Still another physician, Dr. Margo Cohen of New York, wrote about the errors she discovered in the records of doctors caring for her husband’s cancer — how she as the wife had supposedly had long conversations and agreed with the care plans of doctors whom she’d never met.

A patient, Lois Berkowitz, had an interesting suggestion. Before the doctor can save the e-record, the doctor should be required to get the patient’s agreement that the record accurately represents their encounter.

Not practical for all patients or for all situations, still, such a practice would go a long way toward getting us back to the goal: records that are accurate enough that they can safely guide future care and provide a database for malpractice analysis if the patient gets hurt.

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