Sunday, April 27, 2008

"Clinical Plagiarism": Calling EMR copy/paste what it is

Although I'm headed into traditional medical librarianship, being in the thick of healthcare IT for years has left an indelible impression on me. Granted, most of that time I had no earthly clue exactly how the different components I was ordering in my purchasing role to the tune of millions of dollars to avert zomg Y2K!1!!!1!! were or how all the billing systems worked with one another, but during my health informatics classes I had way too many moments of Oh! THAT'S what that was about! I still remember an Ask Me About HL7 button someone had in his office a decade ago, then last year in an agonizing class... there was HL7. Aie! Flashbacks!

As a result of all that, I'm acutely sensitive to the issues surrounding electronic health or medical records (EHRs or EMRs). I'm still not seeing a clear trend in definitions to distinguish one from the other so my own preference is EMR. Whenever I see anyone writing about EMRs, I am usually there. I love seeing the issues from as many viewpoints as possible because there is so much concern and so little agreement over just about every component of them.

One concern I have seen mentioned repeatedly as both a praise (saving time, improving accuracy, insurance coding) and a caution (reducing accuracy due to copying wrong info) is the ability to copy descriptive text that is frequently used in patient records. I have seen some modified versions of this happening as part of my own healthcare, although without grilling the medical staff it appeared to be the use of pre-formatted template wording from one section of my EMR to another that didn't have a template.

Today I read a post in Health Care Renewal, a group blog concerned with "Addressing threats to health care's core values, especially those stemming from concentration and abuse of power" that highlighted a term for this phenomenon from a New England Journal of Medicine editorial that put an entirely different light on it for me: Clinical plagiarism.

It could be that I'm so recently from grad school where we had the Fear of Plagiarism drilled into us more than anything else, but the more I think about it the more I agree with calling a spade a spade. We expect students to research the literature and case studies, but come up with their own terms and thoughts while properly citing their resources. Why should we expect any less from our doctors? Do we want to be the patient who is either copied or pasted, with whatever makes our medical history unique and 'off the charts' (i.e. no standard template wording exists for what we have going on) either carried forward or someone else's information accidentally given to us without our knowledge? Consumer views of EMRs are not full compendiums of medical data and terminology and generally offer summaries of lab tests, after-visit summaries and related material in regular language.

These are the things that keep me up at night if I'm not careful.


RDG said...

Hello Ms. Detmar,

Are you still interested in this subject matter? I've been working in this area for about 6 years now.

There are some new guidelines on the use of copy functions that will be published by the American Health Information Management Association (AHIMA) sometime soon. Their website's public section has material you may find of interest. Let me know if you've found your way there already and, if not, I'll point to a couple links.

Advocates for Documentation Integrity and Compliance

Eagle Dawg said...

Dear Dr. Gelzer,

Thank you for visiting and your update about AHIMA's guidelines for copy functions on EMRs. I am definitely still interested in the subject and also know of but don't know much about what AHIMA (HIMSS & AMIA as well) is currently working on for guidelines.

I would be grateful for public information links about this issue. I will soon post about a 'Librarians and the EHR' forum I attended with Thomas Payne, MD, FACP, FACMI as keynote speaker and would be pleased to share links with credit to you in it.

Thanks and best regards,
N. Dettmar

RDGelzer said...

Good morning Ms. Dettmar,

Here is a link to the public section of the AHIMA website:

I'd recommend readers start with this paper from late 2005, the 14th on the list of documents at the link above.

Update: Maintaining a Legally Sound Health Record--Paper and Electronic

The EMR industry has been remarkably resilient to taking up basic documentation integrity functions, in large part because that is not something demanded by the buyers and users of these systems.

Eventually the accumulated weight of problematic and untrustworthy documentation will spill over into legal cases. Hopefully then the buyers and users of these systems will require better designed systems.

In the meantime, my associate and I have published a screening tool for evaluating EHRs that we gave to AHIMA to publish as an article.

Gelzer, Reed D., Trites, Patricia, "Using Test Vignettes to Assess EHR Capabilities", in Journal of AHIMA, 5/2/06. We have published a more extensive testing methodology in book form. also thru AHIMA.

We find that many practices with EHRs do not know the risks these systems pose to them and so created these testing tools for an objective, reproducible evaluation of systems in place, or systems under consideration for purchase.

Copy functions in EHRs are actually just a subset of the problem of authorship accuracy. Since payment for services is driven by who actually provided the service, there are substantial financial incentives to use EHR capabilities to misrepresent who did what. Patricia A. Trites, of Healthcare Compliance Resources often notes that EMR advertising especially highlights higher reimbursement as the main attractin of an EMR. Another auditing professional, Rebecca Busch of Medical Business Associates, notes that EMRs are simply too tempting to those she terms, "the ethically challenged". My concern is that the majority of doctors, nurses, PAs and other hardworking professionals will be doing things exactly as they should, but their EMR will betray them if ever challenged in a legal setting. For example, EMRs can dutifully record that documentation has been altered but not retain the original version, making it impossible for a doctor to prove that the alteration was not done for improper reasons.

I hope you have success in conveying to others the need for thorough due diligence in evaluating how a system actually works, to make sure it meets the basic requirements for valid, accurate, and trustworthy medical and business records.

Advocates for Documentation Integrity and Compliance