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Impacts of Computerized Physician Documentation in a Teaching Hospital: Perceptions of Faculty and Resident Physicians

Affiliations of the authors: Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR (PJE, TRY, JRL, PNG); Department of Medicine, Veterans Affairs Medical Center, Portland, OR (PJE, TGC); Department of Medicine, Oregon Health & Science University, Portland, OR (JLB, TGC) USA

Correspondence and reprints: Peter J. Embi, MD, MS, University of Cincinnati College of Medicine, 231 Albert B. Sabin Way, ML 0535, Cincinnati, OH 45267-0535.; e-mail: <mail{at}embi.net>

Received for publication: 01/02/04; accepted for publication: 03/11/04.

Objective: Computerized physician documentation (CPD) has been implemented throughout the nation's Veterans Affairs Medical Centers (VAMCs) and is likely to increasingly replace handwritten documentation in other institutions. The use of this technology may affect educational and clinical activities, yet little has been reported in this regard. The authors conducted a qualitative study to determine the perceived impacts of CPD among faculty and housestaff in a VAMC.

Design: A cross-sectional study was conducted using semistructured interviews with faculty (n = 10) and a group interview with residents (n = 10) at a VAMC teaching hospital.

Measurements: Content analysis of field notes and taped transcripts were done by two independent reviewers using a grounded theory approach. Findings were validated using member checking and peer debriefing.

Results: Four major themes were identified: (1) improved availability of documentation; (2) changes in work processes and communication; (3) alterations in document structure and content; and (4) mistakes, concerns, and decreased confidence in the data. With a few exceptions, subjects felt documentation was more available, with benefits for education and patient care. Other impacts of CPD were largely seen as detrimental to aspects of clinical practice and education, including documentation quality, workflow, professional communication, and patient care.

Conclusion: CPD is perceived to have substantial positive and negative impacts on clinical and educational activities and environments. Care should be taken when designing, implementing, and using such systems to avoid or minimize any harmful impacts. More research is needed to assess the extent of the impacts identified and to determine the best strategies to effectively deal with them.

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