Recently I read a post over at Medwire News citing a that investigated whether the copy-and-paste methodology could have detrimental effects on diabetes control. Since I previously blogged on this topic, of course I found the study very interesting. In their study, the authors used a software program to correlate hemoglobin A1c reductions (a marker of diabetes control) with how often copy-and-paste was likely used. The software guessed at whether parts of a note met enough similarity to previous notes to suggest that they might have originated by copy-and-paste methods. Because the diabetic patients being followed in the copy-and-paste group did not have lower hemoglobin A1c levels over time, the authors concluded that copy-and-paste had a role in causing bad patient outcomes.
Although interesting, this study is concerning for several reasons. It places a bad view (real or not) on doctors who use copy-and-paste responsibly and effectively. Since I do this all the time and have not noted any particularly bad outcomes in my diabetes patients, I have to question whether the conclusion is valid. There is so much potential for error in this type of statistical correlation research that I think big disclaimers should be noted. What kind of counseling was being done in the subgroup of diabetics that had an allegedly poorer outcome? Was that group of diabetics different from the ones with a good outcome? What approaches to treatment were used? What years were they being treated? Who was treating them? Etc, etc. Perhaps the most important two questions in my mind are: Who are the authors responsible for the study? What are the authors’ personal biases?
The authors conclude that “These results lead us to question whether copied electronic documentation is a reliable representation of patient care,” in a letter to the Archives of Internal Medicine. “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.” There seems to be such a negative slant here that I have to again ask about the personal biases of the authors and how this may have affected their study design.
What would be my motivation to enter documentation that said I did things that I didn’t actually do? That could also be an important question with multiple possible answers. How much time does the doctor have? Is the doctor a resident trainee? How protective of the practice does the doctor feel? Does quality of electronic notes in general (which is highly varied) directly correlate with patient outcomes? Maybe, since the data from Brigham and Women’s Hospital suggests falsification in the author’s eyes, they should take a good, long look at the context of their research methodology (who was involved in writing the clinical notes and under what circumstances) rather than relying on a possibly very flawed method to generalize negative study results to all doctors using reasonable and responsible documentation methods. Or maybe I’m being too rash?
Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009. He can be reached at email@example.com.