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Exploring Provider Perceptions and Attitudes toward Copy-Paste and Copy-Forward in Clinical Documentation.

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Area of Science:

  • Health Informatics
  • Medical Documentation
  • Electronic Health Records (EHRs)

Background:

  • Copy-paste (CP) and copy-forward (CF) are prevalent tools in EHR systems, intended to enhance provider efficiency.
  • However, these tools may contribute to increased documentation burden, note bloat, and potential errors, with limited understanding of provider perceptions.
  • Provider perspectives on the impact of CP and CF on documentation quality and efficiency remain underexplored.

Purpose of the Study:

  • To investigate provider perceptions and self-reported usage patterns of CP and CF.
  • To analyze how these tools affect clinical documentation quality and efficiency across various clinical environments and provider roles.
  • To understand provider attitudes towards the future use of CP and CF.

Main Methods:

  • A survey was developed and administered to medical students, trainees, and faculty at a large academic medical center.
  • The survey collected data on documentation practices, perceived benefits and risks of CP/CF, and future use attitudes.
  • Quantitative and qualitative analyses were performed on data from 913 respondents.

Main Results:

  • High utilization of CP (82%) and CF (52%) was reported, with significant variation by clinical environment (e.g., highest in inpatient primary services, lowest in EDs).
  • Most providers (86%) believed CP/CF improved efficiency, yet a majority acknowledged that these tools worsened documentation errors.
  • Providers preferred copying their own notes (90% CP, 82% CF) over others' notes (61% CP, 47% CF).

Conclusions:

  • Self-reported use of CP and CF is high, driven by perceived efficiency gains, despite awareness of associated documentation errors and note bloat.
  • Usage patterns and perceptions of CP/CF differ across practice environments, indicating a need for nuanced, workflow-specific solutions.
  • Future interventions should balance documentation quality with efficiency, considering the specific practice environment and provider role.