Physicians within three departments (two pediatric, one medicine) of two large, affiliated, academic hospitals were given a self-administered survey over an 8-week study period between June and August 2007.
Survey Sites and Documentation System The three departments of the two academic medical centers included in this study were the pediatric and medicine departments of Hospital A, a 798-bed hospital with 27,500 discharges annually, and the pediatric department of Hospital B, a free-standing children’s hospital with 283 beds and 12,300 discharges annually. The medicine department of Hospital B was not using a computerized documentation system at the time of the survey. The three study departments had inpatient electronic note writing capabilities as part of a commercial electronic medical record system for at least 3 years. The CCHIT (Certification Commission for Health Information Technology) certified vendor system offered preconfigured templates for inpatient note documentation, including admission, progress, procedure and discharge notes. Most information was entered as free text by physicians. Certain vital signs and laboratory values could be imported directly into notes from flow sheets. Each hospital used a different version of the system.
In Hospital A’s older version, each templated note was a single free text document. Physicians could copy all or parts of a previous note. Hospital B had switched from this version to a newer version of the documentation system a year prior to survey. In this new version, templated notes were separated into different text boxes or fields (including subjective, past medical history, assessment and plan). The physical exam field could be completed using a checklist or free text. Physicians could use a ‘copy forward’ function in which separate note fields could be individually forwarded into fields of a new note. Physicians could still copy and paste in this system by writing notes as free text documents instead of templated documents, or by copy and pasting each field of the note separately into a new note. Both pediatric departments required all resident and general pediatrician notes to be electronic, while consult service and specialist participation were varied. In the medicine department, writing notes electronically was not mandatory.
Survey Population All resident physicians in the three departments were included in this study. Five faculty divisions of each department were selected for inclusion: the four divisions with the largest inpatient services (general pediatrics or internal medicine, critical care, cardiology and oncology) and one division with primarily inpatient consulting responsibility (infectious disease). The division faculty lists were reviewed by department leaders and division chairs to identify physicians who completed at least 2 weeks of clinical inpatient service in the last academic year.
Survey Instrument We identified important considerations regarding CPF by literature review and key informant interviews. Relevant articles found in Ovid Medline using the key word searches: ‘copy and paste’ and ‘computerized physician documentation’ as well as the subject headings: ‘copying processes,’ ‘user computer interface,’ ‘documentation,’ ‘medical records systems, computerized,’ ‘attitudes to computers’ and ‘attitudes of health personnel’ were reviewed. In addition, 15 semi-structured interviews were conducted with residents, faculty physicians and leaders within the hospital areas of patient safety, legal affairs, billing compliance and clinical informatics. All interviewees reported the ability to distinguish between progress notes written with and without CPF by comparing them to the previous patient notes. Ideas and concepts from these two sources were translated into survey questions and pilot tested for clarity and content validity by an additional 15 residents and faculty.
The 22-question survey incorporated a definition of CPF that included the copy-forward function and excluded the automatic insertion of vital signs and results. Respondents were asked whether they wrote inpatient notes electronically on the hospital documentation system, on paper or a combination of both. Physicians who wrote at least some notes electronically were asked about their comfort level writing notes electronically and the frequency and pattern of their CPF use. All opinions were assessed using five-point Likert scales. Physicians who acknowledged reading electronic notes were asked how frequently they noted flaws in progress notes written using CPF compared to other electronic notes, how CPF affected physician documentation overall and CPF’s effect on the ability of progress notes to serve several purposes (e.g., to communicate a patient’s daily course, to document a patient’s entire course or to document for billing or legal purposes). They were also asked if they have ever made a mistake in patient care that they felt was a result of being confused by a note containing copy and pasted text (yes, no or unsure) and asked their opinion of several proposed changes to CPF use. Demographic information collected included gender, training level, year of birth and year of medical school graduation. A copy of the survey is available online as an appendix.
Data Collection The study protocol and survey were approved by the Institutional Review Boards of the two hospitals before the confidential, self-administered survey was sent to all eligible physicians via e-mail using an online survey tool. Non-respondents were sent two additional e-mail surveys at 2-week intervals and were contacted by phone or page a maximum of two times. In addition, paper copies were brought to resident conferences, and a paper copy was mailed to the offices of all faculty non-respondents. No financial incentives were given for the completion of the survey.
Statistical Analysis Comparisons between (1) survey respondents and non-respondents, (2) electronic note writers (physicians who wrote their inpatient notes electronically on the hospital system) and non-electronic note writers (physicians who wrote paper notes) and (3) CPF users and non-CPF users (including electronic note writers who never used CPF and non-electronic note writers) were performed using chi-square or Fisher exact tests for categorical variables, and t-tests, or ANOVA for continuous variables. Multivariate logistic regression models were used to determine independent predictors associated with (1) electronic note writers versus non-electronic note writers and (2) high (used CPF almost always or most of the time when writing progress notes) versus low CPF use (used CPF sometimes or rarely). All analyses were performed using SAS for PC version 9.1.