The patient health record serves as the repository for all information relevant to the care of a patient in a hospital or health care system, and clinical documentation is the core of this record. Among the many purposes of today's health record,1
communication of patient-related details among clinicians remains the most important. The traditional paper record often lacks accessibility, legibility, and flexibility, reducing its effectiveness as a communications tool.2,3,4
These limitations have driven many institutions to adopt electronic health records (EHRs).
Advances in EHRs have made it possible to computerize many functions of the patient health record. While the inclusion of physician documentation in EHRs has traditionally occurred through the use of transcribed dictation, this is expensive and can produce substantial delays in document availability.5,6
To address these issues, some EHRs allow for direct entry of physician documentation via a computer keyboard and mouse, a process we refer to as computerized physician documentation (CPD).
One EHR that provides CPD capability is the Veterans Administration's Computerized Patient Record System (CPRS). In addition to allowing physicians to type directly into the chart, CPRS provides document templates, “copy-and-paste” functions, and automated insertion of clinical data to facilitate the sometimes-burdensome task of documentation. Since the release of CPRS in 1998, most Veterans Administration Medical Centers (VAMCs) have mandated that clinicians make the transition from paper-based documentation to CPRS-based CPD.
The creation and review of clinical documentation are integral not only to the practice of medicine, but also to the teaching and learning of it.7
CPD has the potential to improve these activities through better document accessibility, increased legibility, and decreased costs. However, studies of EHR-based documentation effects have yielded mixed results. While some have found that the use of an EHR resulted in “more complete” and “more understandable” documentation when compared with paper-based records,8,9
others have noted that EHR-based documentation may promote the completion of such information-intensive tasks at the expense of patient communication.10
In addition, earlier research suggests that a transition from paper to computer-based documentation might have other unintended impacts. Nygren and Henriksson11
showed that the format, layout, and other textural features of the paper record are critical to a physician's ability to search, read, and assess the relevance of information contained therein. Features such as the ability to manually tabulate pertinent data and mark up abnormal findings may be important to the cognitive processing of clinical information and could be lost with CPD. Indeed, more recently conducted research by Patel et al.12
found that EHR use was associated with changes in physicians' cognitive behaviors such as information gathering, organization, and reasoning strategies.
Furthermore, the implementation of new technology into complex social systems often results in unanticipated consequences. Negative effects on clinical practice, organizational culture, and medical education have been documented to result from the transition to other EHR-based technologies, including computerized physician order entry (CPOE).13,14,15,16
However, unlike other such EHR components, which have undergone substantial evaluation in recent years,17,18,19,20,21
relatively little research has been focused on defining the impacts of CPD.
Because of the potential for important effects from the use of CPD, the likelihood that this technology will proliferate, and the paucity of research related to its use in the inpatient setting, we set out to identify the range of clinical and educational impacts that are perceived to have been caused by the transition to CPD in a teaching hospital.