BackgroundElectronic health records (EHRs) can aid in provider efficiency, but may also lead to unintended consequences, such as documentation burden and increased length of notes. To combat issues related to documentation, copying and pasting (CP) and copying or carrying forward (CF) are tools that have been used to aid in documentation burden. Multiple studies have identified the benefits and challenges of using these tools; however, few studies have identified the unintended consequences of CP and CF, and how the adoption of these tools may affect users. ObjectiveThe objective was to describe providers’ perceptions and use of copying tools available in the EHR and describe their suggestions for improvement on these copying tools. MethodsResearch team members conducted semistructured interviews with faculty members, advanced practice providers, residents or fellow trainees, and medical students at a single academic health sciences center. The Diffusion of Innovations Theory of Unintended Consequences guided the analysis and interpretation of interview results. ResultsA total of 22 semistructured interviews were conducted in 2023 and analyzed during 2024. The findings showed that respondents use and value these tools for efficiency and communication purposes. The negative unintended consequences include inaccuracies and errors in documentation and increased patient safety risks. Some respondents experience inner angst or moral injury related to using CP/CF, but they feel that they must use them to satisfy organizational requirements surrounding documentation. The respondents suggested that artificial intelligence will likely help improve documentation tools, as would further training around these types of documentation tools. ConclusionsSome respondents noted feeling both internal and external pressures that influenced when and how they use CP/CF. Respondents noted that they value EHR copying tools for efficiency purposes, but they also understand the risks involved. This tension may lead to moral angst or moral injury. They offered numerous suggestions for lowering the risk, especially by improving the documentation capabilities of the EHR through artificial intelligence. Future research should investigate both technical and educational solutions to relieve the documentation burden and moral angst they are experiencing.

Copy-paste (CP) and copy-forward (CF) are common electronic health record (EHR) documentation tools that purportedly improve provider efficiency, but they can also contribute to documentation burden while increasing note bloat and errors. Our understanding of provider perceptions of these tools remains limited.This study aimed to increase understanding of provider perceptions and self-reported usage patterns of CP and CF across different clinical environments and provider roles, including the impact of these tools on clinical documentation quality and efficiency.A survey was developed and administered at a large academic medical center from December 2022 to March 2023. The survey was distributed to medical students, trainees, and faculty. Questions addressed documentation practices, perceived benefits and risks of CP/CF, and attitudes toward future use. Data were analyzed both quantitatively and qualitatively.Among 913 respondents (22-28% response rate across levels of training), 82% reported using CP, and 52% used CF in clinical documentation. Usage varied significantly by environment, with the highest utilization in inpatient primary services (91% CP, 68% CF) and the lowest in emergency departments (70% CP, 14% CF). Eighty-six percent of providers believed that CP/CF improved efficiency. A majority felt that CP (59-70%) and CF (69-76%) worsened several types of documentation errors. Providers showed stronger acceptance of copying from their own notes (90% CP, 82% CF) compared with others' notes (61% CP, 47% CF).Self-reported use of CP and CF is high by providers, driven by perception of improved efficiency despite recognition that these tools contribute to documentation errors and note bloat. Use varies by practice environment. CP is viewed more favorably compared with CF, as is copying one's own documentation compared with that of another provider. This suggests that solutions should be nuanced and workflow-specific. Future interventions must balance documentation quality with efficiency and take the practice environment and provider role into account.

This chapter describes how to design studies that seek to determine the impact of an information resource, various methods including randomization that are used to achieve control in such studies, and some of the specific biases that can affect interventional studies of information resources. It concludes with a section on sample size and study power.

BACKGROUND:The use of electronic health records has generated an increase in after-hours and weekend work for providers. To alleviate this situation, the hiring of medical scribes has rapidly increased. Given the lack of scribe industry standards and the wide variance in how providers and scribes work together, it could potentially create new patient safety-related risks.OBJECTIVE:The purpose of this paper was to identify how providers can optimize the effective and safe use of scribes.DESIGN:The research team conducted a secondary analysis of qualitative data where we reanalyzed data from interview transcripts, field notes, and transcribed group discussions generated by four previous projects related to medical scribes.PARTICIPANTS:Purposively selected participants included subject matter experts, providers, informaticians, medical scribes, medical assistants, administrators, social scientists, medical students, and qualitative researchers.APPROACH:The team used NVivo12 to assist with the qualitative analysis. We used a template method followed by word queries to identify an optimum level of scribe utilization. We then used an inductive interpretive theme-generation process.KEY RESULTS:We identified three themes: (1) communication aspects, (2) teamwork efforts, and (3) provider characteristics. Each theme contained specific practices so providers can use scribes safely and in a standardized way.CONCLUSION:We utilized a secondary qualitative data analysis methodology to develop themes describing how providers can optimize their use of scribes. This new knowledge could increase provider efficiency and safety and be incorporated into further and future training tools for them.

This chapter is the first of four that describe the challenges that arise in designing and analyzing the result of demonstration studies, and focuses specifically on descriptive studies. It considers first the key characteristics of demonstration studies and how the three kinds of demonstration studies (descriptive, interventional and correlational studies) differ, then discusses the challenges of conducting descriptive studies, dividing these into threats to internal and external validity. The chapter then describes some methods to analyse the results arising from descriptive studies.

This chapter introduces the important steps that precede and conclude the actual conduct of a study. The chapter discusses in depth what is required to propose a study to potential funders and other stakeholders. It also explores the many options for communicating the results after a study is complete.

This chapter completes the discussion of measurement by offering techniques to create measurement processes that are reliable and valid. The chapter separately addresses measurement processes where judges of observed behavior, tasks completed by people or machines, and items on forms are the types of observations of primary interest. For each type of observation, the chapter considers the sources of variation in measurement results, how many observations are needed for reliable measurement, and how to improve the measurement process.

This chapter introduces the multiple approaches to evaluation. The availability of multiple approaches provides a mechanism to address the challenges described in the previous chapter. The discussion traces the origin of these varying approaches to their very different philosophical origins.

This chapter extends the concepts of measurement introduced in the previous chapter to addressed the more practical matters of how measurement processes are actually improved through measurement studies. The specific topics addressed are how to identify observations that are not well-behaved, standard errors of measurement, and how to take into account the effects of measurement errors on the results of demonstration studies.

This chapter introduces the purposes and many of the complexities of conducting evaluation studies in biomedical and health informatics. It describes the work of informatics and how evaluation in general supports that work. It distinguishes evaluation from research, offers specific purposes that motivate evaluation studies, and describes several challenges that add complexity to informatics evaluations.

While the prior chapter set the stage for an understanding of the nature of qualitative evaluation, this chapter will offer strategies for planning a study and making decisions about how to gather data. The process is depicted as an iterative looping through steps beginning with idea generation to dissemination of results. It is critical that strategies for rigor be incorporated throughout the process. This chapter outlines methods for data collection utilizing interviews, focus groups, observation, and naturally occurring data, and then it also describes combinations often used together, which constitute toolkits of complementary techniques.

This final chapter introduces a number of thought-provoking challenges that need to be addressed if ICT evaluation efforts are to succeed in helping to improve ICT and its impact of the quality of healthcare. It first describes ethical challenges related specifically to informatics evaluation projects, including unique human subjects issues and assuring the safety of ICT itself. It then focuses on ethical challenges during each phase of an evaluation project. The chapter concludes with a description of the authors’ closing thoughts about the future of evaluation methods and efforts in informatics.

This chapter, a companion to Chap. 3 , provides four realistic scenarios illustrating common reasons for performing evaluations and a description of the studies that might be performed. It also includes an example of a published study, illustrating the ten informatics-specific study types introduced in Chap. 3 .

Objective While the use of medical scribes is rapidly increasing, there are not widely accepted standards for their training and duties. Because they use electronic health record systems to support providers, inadequately trained scribes can increase patient safety related risks. This paper describes the development of desired core knowledge, skills, and attitudes (KSAs) for scribes that provide the curricular framework for standardized scribe training. Materials and Methods A research team used a sequential mixed qualitative methods approach. First, a rapid ethnographic study of scribe activities was performed at 5 varied health care organizations in the United States to gather qualitative data about knowledge, skills, and attitudes. The team’s analysis generated preliminary KSA related themes, which were further refined during a consensus conference of subject-matter experts. This was followed by a modified Delphi study to finalize the KSA lists. Results The team identified 90 descriptions of scribe-related KSAs and subsequently refined, categorized, and prioritized them for training development purposes. Three lists were ultimately defined as: (1) Hands-On Learning KSA list with 47 items amenable to simulation training, (2) Didactic KSA list consisting of 32 items appropriate for didactic lecture teaching, and (3) Prerequisite KSA list consisting of 11 items centered around items scribes should learn prior to being hired or soon after being hired. Conclusion We utilized a sequential mixed qualitative methodology to successfully develop lists of core medical scribe KSAs, which can be incorporated into scribe training programs.

This chapter is the first of three devoted to describing qualitative methods for evaluating informatics interventions. Its major goals are to describe when qualitative methods are appropriate and to offer a general framework for understanding how studies using these methods are conducted. Chapters 15 and 16 provide much more detailed tours through the methods of qualitative evaluation.

This chapter introduces the methods of quantitative studies. It describes the process of measurement, which is fundamental to all quantitative methods, and then offers an important distinction between measurement and demonstration studies. The chapter concludes with a description of three types of demonstration studies: descriptive, interventional, and correlational.

Prior chapters have described the rationale and methods for conducting different types of quantitative and qualitative evaluation studies. This chapter will describe how the two strategies can be used in an integrated manner, a mixed methods approach, to take advantage of the benefits of both strategies. The chapter outlines a nomenclature and typology for mixed methods studies and describes usability studies and organizational-systems level studies as examples of mixed methods designs useful in informatics.

This chapter begins an in-depth study of measurement by introducing the “classical theory” of measurement, which serves this book’s level of discussion. The classical theory hinges on the concepts of reliability and validity as the indices of the quality of the measurement process. According, this chapter develops both concepts, and introduces methods for determining the reliability and validity of any given measurement process.

This chapter address evaluation studies specifically in biomedical and health informatics. It introduces methods for identifying and expressing the questions that give focus to a study. It then describes ten informatics-specific study types that can guide study teams toward a design that is a best match to the study questions.