Electronic Medical Records Are a Mess! Here's Why.

This video provides an in-depth exploration of the critical issues plaguing Electronic Medical Records (EMRs), specifically focusing on the pervasive problem of "copy and paste" documentation and its detrimental effects on healthcare quality and patient safety. Dr. Eric Bricker, an internist, explains that EMR documentation serves three primary purposes: communication among healthcare practitioners, justification for billing, and as a legal record. He argues that the stringent and complex requirements for billing codes, particularly Evaluation and Management (E&M) codes (e.g., 99201-99205 for new patients, 99211-99215 for established patients), force doctors to document extensive details about patient history, physical exams, and medical decision-making (often structured as SOAP notes).

The core of the problem, according to Dr. Bricker, lies in the EMR's word-processing-like "copy and paste" functionality. Faced with overwhelming documentation demands, doctors frequently copy previous notes—either their own or those of other clinicians—to save time and meet billing requirements. This practice, while seemingly efficient, leads to a massive accumulation of redundant and often inaccurate information within patient records. Dr. Bricker cites a significant study published in the Journal of the American Medical Association (JAMA) on September 26, 2022, conducted at the University of Pennsylvania Hospital System, which found that 50% of EMR text across inpatient, outpatient, and ER notes was copied and pasted. This percentage increased from 33% in 2015 to 54% in 2020, with AI being used to identify verbatim text.

The consequences of this widespread copy-pasting are severe. Firstly, it creates "chart lore," where outdated or incorrect information (e.g., misidentified allergies) is perpetuated throughout the record, potentially leading to suboptimal or harmful patient care. Secondly, it results in immense information overload, making EMRs incredibly long and difficult to navigate. Dr. Bricker vividly illustrates this by stating that the average patient record is 56% the length of Shakespeare's "Hamlet," and reviewing records for just 10 patients is equivalent to reading an 85-page book, with nearly half of it being copied "junk." This forces doctors to skim records, increasing the likelihood of missing crucial "golden nuggets" of information, which can lead to medical errors and patient harm. He concludes by highlighting a rare positive example from the Sanford hospital system (South Dakota), which uses structured note templates to minimize copy-pasting and promote succinct, effective communication, ultimately leading to better patient care.

Key Takeaways:

• Fundamental Flaw in EMR Documentation: Electronic Medical Records are inherently flawed due to the pervasive practice of "copy and paste" documentation, driven primarily by complex billing requirements rather than optimal patient care.
• Threefold Purpose of EMR Notes: Documentation in EMRs serves to facilitate communication among healthcare providers, justify billing for services rendered, and act as a legal record in case of disputes.
• Billing Code Complexity Drives Documentation Volume: Evaluation and Management (E&M) codes (e.g., 99201-99205, 99211-99215) mandate extensive and specific documentation regarding patient history, physical exams, and medical decision-making, including face-to-face time.
• Pervasive Copy-Pasting: The "copy and paste" function within EMRs, while a perceived time-saver for busy clinicians, is widely abused. A JAMA study from the University of Pennsylvania found that 50% of EMR text was copied and pasted, increasing from 33% to 54% between 2015 and 2020.
• AI for Text Analysis: The study utilized Artificial Intelligence to analyze EMR text and identify verbatim copied content, demonstrating AI's capability in uncovering documentation patterns and quality issues.
• "Chart Lore" and Inaccurate Information: Copy-pasting leads to the propagation of "chart lore," where outdated or incorrect information (e.g., non-allergies like metallic taste from contrast dye) is repeatedly documented, potentially leading to inappropriate medical decisions.
• Severe Information Overload: The volume of copied text creates massive information overload, making EMRs excessively long and difficult to review. An average patient record is 56% the length of Shakespeare's "Hamlet."
• Increased Risk of Medical Errors: Doctors are forced to skim through voluminous, redundant records to find critical information, significantly increasing the risk of missing vital details and contributing to medical errors and patient harm.
• Doctor Reluctance for Universal Records: The overwhelming amount of irrelevant "junk" data in EMRs makes many doctors resistant to universally shared medical records, as it would necessitate reviewing even more extraneous information.
• Structured Templates as a Solution: The Sanford hospital system provides an example of a potential solution by implementing structured note templates within their EMR to minimize copy-pasting and encourage succinct, effective communication.
• Value of Succinct Documentation: Highly succinct, clear, and focused notes, often exemplified by surgeons' documentation, are more effective communication tools and contribute to better patient care.
• Tension Between Billing and Care: A fundamental tension exists between the detailed documentation required for billing purposes and the concise, relevant information needed for efficient and safe patient care.

Tools/Resources Mentioned:

• AI: Used in the University of Pennsylvania study to analyze EMR text for copied content.
• EMR Systems: Generic reference to prominent EMR systems with copy-paste functionality (unnamed).
• Journal of the American Medical Association (JAMA): Source of the study on EMR copy-pasting.

Key Concepts:

• Electronic Medical Records (EMR): Digital versions of patient charts, central to healthcare documentation.
• Evaluation and Management (E&M) Codes: A category of CPT codes used by physicians to bill for patient visits based on complexity.
• CPT Codes: Current Procedural Terminology codes, used to describe medical, surgical, and diagnostic services.
• SOAP Notes: A common method of documentation in medical records, standing for Subjective, Objective, Assessment, and Plan.
• Chart Lore: The phenomenon where incorrect or outdated information is perpetuated in a patient's medical record through repeated copying and pasting.
• Information Overload: The state of being exposed to too much information, making it difficult to make decisions or extract relevant details.

Examples/Case Studies:

• University of Pennsylvania Hospital System Study: A six-year study (2015-2020) that found 50% of EMR text was copied and pasted, increasing over time, and used AI for analysis.
• Sanford Hospital System (South Dakota): Cited as an example of a system that uses note templates to minimize copy-pasting and encourage succinct documentation, leading to better communication and patient care.