JMIR Publications

ABSTRACT

Background:

Background:

Electronic health records can aid in provider efficiency, but may also lead to unintended consequences, like documentation burden and increased length of notes. To combat issues related to documentation, copying and pasting and copying/carrying forward are tools that have been utilized to aid in documentation burden. Multiple studies have identified the benefits and challenges of using these tools, however, few studies have identified the unintended consequences of copy/paste and carry forward, and how the adoption of these tools may affect users.

Objective:

Objective:

The objective was to describe providers’ perceptions and use of copying tools available in the electronic health record and describe their suggestions for improvement on these copying tools.

Methods:

Methods:

Research team members conducted 22 semi-structured interviews with faculty members, advanced practice providers, graduate medical education trainees, and medical students at a single academic health sciences center. The Theory of Unintended Consequences guided the analysis and interpretation of interview results.

Results:

Results:

Providers use and value these tools for efficiency and communication purposes. Residents, who are often responsible for documentation, are primary users of these tools. Negative unintended consequences include inaccuracies and errors in documentation and increased patient safety risks. Providers experience inner angst/moral injury related to using these documentation tools, but they feel that they must use them to satisfy organizational requirements surrounding documentation. The providers believe artificial intelligence (AI) will likely help improve documentation tools as would further training around these types of documentation tools.

Conclusions:

Conclusions:

Interviewees noted feeling both internal and external pressures that influenced when and how they use copying tools. Interviewees noted that they value EHR copying tools for efficiency purposes, but they also understand the risks involved. This tension leads to moral angst. They offered numerous suggestions for lowering the risk, especially by improving documentation capabilities of the EHR through AI. Future research should investigate both technical and educational solutions to relieve the documentation burden and moral angst they are experiencing Clinical Trial: N/A