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

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.