Electronic Health Records .. do they reveal actual Patient Care ?

Copy/Paste Documentation of Lifestyle Counseling and Glycemic Control in Patients With Diabetes: True to Form?

http://archinte.ama-assn.org/cgi/content/full/archinternmed.2011.219v1

(May 23, 2011 online first edition of Archives of Internal Medicine)

This was a study of patients with diabetes to determine the relationship between copied lifestyle counseling documentation and glycemic control.

Comments:
In this large retrospective study of copied documentation of lifestyle counseling in patients with diabetes, we have demonstrated that, unlike original records, copied documentation of lifestyle counseling was not associated with improvement in glucose control. In fact, its effect on HbA1c was undistinguishable from no counseling at all. These findings were consistent for all 3 types of lifestyle counseling we analyzed—diet, exercise, and weight loss. These results lead us to question whether copied electronic documentation is a reliable representation of patient care. If it is not, it could be either an honest mistake or deliberate falsification. In the latter case, copied documentation that does not reflect the actual events is a serious breach of medical ethics. In either case, it carries a significant financial and legal risk.
Efforts must therefore be made to decrease the incidence of inappropriately copied electronic documentation. These could include training and education of health care providers as well as technical solutions, such as software that automatically detects overly similar notes or their components. In order for EMRs to benefit patients, we must make sure the information they contain is meaningful.