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Copy Tools in the Electronic Health Record: Perceptions, Implications, and Future Directions.

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Summary

Healthcare providers use electronic health record (EHR) copying tools for efficiency but face documentation errors and moral injury. They suggest AI and better training to improve EHR documentation tools and reduce risks.

Keywords:
attitude of health personnelcarry-forwardclinical communicationclinical documentationcopy-pasteelectronic documentationelectronic health recordshuman factorsqualitative research

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Area of Science:

  • Medical Informatics
  • Healthcare Technology
  • Clinical Documentation

Background:

  • Electronic health records (EHRs) offer efficiency but can increase documentation burden.
  • Copying and pasting (CP) and copying forward (CF) tools are used to mitigate documentation workload.
  • Unintended consequences of CP/CF tools on users are not well-understood.

Purpose of the Study:

  • To explore healthcare providers' perceptions and usage of EHR copying tools.
  • To gather suggestions for improving these documentation tools.

Main Methods:

  • Semistructured interviews were conducted with diverse healthcare professionals at an academic health sciences center.
  • The Diffusion of Innovations Theory of Unintended Consequences guided the qualitative analysis.

Main Results:

  • Providers value CP/CF tools for efficiency and communication.
  • Negative consequences include documentation inaccuracies, patient safety risks, and moral injury due to organizational pressures.
  • Suggestions for improvement include AI integration and enhanced training.

Conclusions:

  • A tension exists between the perceived efficiency of EHR copying tools and their associated risks.
  • This tension can lead to moral angst or injury for providers.
  • Improving EHR capabilities with AI and providing targeted education are key to reducing documentation burden and moral distress.