JMIR Publications

ABSTRACT

Background:

Clinical documentation plays a crucial role in providing and coordinating care. Despite the widespread adoption of electronic health record systems (EHRs), many end-users still document clinical data in a manner similar to traditional paper-based records. To fully leverage the benefits of EHRs, it is necessary to adopt new documentation approaches that facilitate easy access to information at the point of care and seamless exchange of information across healthcare facilities.

Objective:

To evaluate how the transition from an older EHR to a cross-institutional EHR impacts medical doctors' documentation practices and to gain a deeper understanding of the factors influencing their choice between free text and structured and standardized documentation methods.

Methods:

A qualitative study was conducted between September 2023 and January 2024. The study involved participant observations and individual semi-structured interviews with medical doctors at a university hospital in Norway. Data was analyzed using reflexive thematic analysis.

Results:

The analysis revealed three main themes. Firstly, medical doctors encountered challenges during the implementation phase of the new EHR due to the complexity of the system and their unfamiliarity with its use. However, with time, medical doctors gradually adopted new documentation processes. This integration/adoption primarily occurred by learning through practical experience and collaborative knowledge exchange with their peers. Secondly, although the implementation of the new EHR has increased standardized clinical documentation, free text remains the preferred method, with some exceptions. Additionally, the fact that many doctors still rely on free text documentation creates a sense of distrust among doctors toward some of the standardized clinical data. Lastly, the informants had mixed perceptions of SNOMED CT. Some viewed it as a more nuanced terminology system, while others found it more complex. The majority of informants found using templates for routine procedures beneficial as it saves time in the documentation process and ensures that all necessary parameters and documentation requirements are met.

Conclusions:

The study findings revealed that medical doctors' acceptance of new documentation processes is influenced by various social and technological factors. These factors include previous documentation experiences, perceived benefits, familiarity with the EHR, time constraints, and user-friendliness of the system. While doctors generally have a positive attitude towards using templates for routine procedures, they often create their own templates, and data within these templates is documented in a free text format. To address this, healthcare organizations should consider implementing common standardized, or semi-standardized templates to reduce disparities in documentation, enhance data recording, and ensure adherence to guidelines. Furthermore, to facilitate the transition to the new documentation processes, we recommend providing medical doctors with customized training programs and platforms for tacit knowledge exchange.