The inferior aspect of the model (Figure 1) indicates there are societal or systems pressures influencing how and when CP/CF are used. Use of CP/CF varied greatly by type of patient visits, setting, specialty, and attributes of the EHR product.

The use of CP/CF differed depending on the type of patient visit (eg, telephone, virtual, or in-person visit; returning, new, or old patient). With a new patient, providers reported using CP to gather the patient’s historical information, especially when the history was complex and involved many images. However, there were some notable differences in use among clinicians. For example, a surgical resident/fellow trainee noted that he was more likely to write down verbal history when meeting a patient for the first time versus gathering prior information and using CP. Other providers mentioned that they do not use CF because they view each visit as a new visit.

According to our respondents, CP/CF use is influenced by whether care is provided in an ambulatory or inpatient setting. For example, CF has been described as “the backbone of all (in-)patient charting” (APP) because it aids in the continuity of care between team members, which would not be applicable in ambulatory settings. Providers who work in both inpatient and outpatient settings mentioned using CP in both settings because they are used to doing so.

Respondents described how different workflows and documentation requirements impact CP/CF use. When providers see long-term patients for chronic problems, they rely on CP/CF, but if they consistently see new patients, such as in emergency medicine, they tend not to use them.

Specialties vary in how they structure their notes, impacting the value of CP/CF. Those with more structured and templated notes used CP/CF less frequently, whereas other specialties required documentation of detailed thought processes and thus were less structured and used CP/CF more frequently. Volume and duration of the patient visits differed by specialty, which impacted providers’ use of CP/CF, with one faculty member noting, “when I’m busier, I tend to copy/paste more and copy forward more” (faculty). The research team also noted that the value found in using CP/CF differed by specialty, so developing a single policy to guide CP/CF throughout a health system would be challenging.

EHRs vary based on product offerings and integration into a system, including access to and policies for use of duplicative text tools. One resident/fellow trainee compared one academic center’s commercial EHR to the Veterans Affairs’ EHR, noting that CP is not easy to do, and CF is not available at all.

The right aspect of the model (Figure 1) features the intended and unintended consequences of implementing any new technology. Our analysis revealed intended benefits from the innovation of CP/CF tools.

When asked about the benefits of CP/CF, many respondents highlighted that these tools were “a survival mechanism” (faculty) that streamlines work processes, decreases documentation time, and increases efficiency, which reduces provider stress and promotes work/life balance.

Part of the CP/CF’s efficiency is derived from organization and time management, allowing providers to update relevant data in a template rather than recreating an entire note from scratch. When used this way, CF can provide consistency, organization, and standardization of notes, helping providers find salient information quickly.

Respondents discussed CP/CF’s enhancement of communication within and across teams and disciplines and settings, which “saves [them] a great deal of time” (faculty). CP/CF help providers stay organized in their notes, which allows them to solve problems together.

CP/CF may decrease errors in translating complicated or nuanced data from note to note, especially from specialists or when dictating notes. One example noted was radiology, because the integrity and accuracy of the original report should stay intact, and providers “don’t have translational[/dictation-relations] errors” (faculty).

While innovations bring about intended and desirable consequences, unintended consequences can also affect the adoption of innovations (Figure 1). Although the diffusion of CP/CF into EHR systems could be considered a success, respondents discussed the risks and challenges CP/CF use presented, which shaped their willingness to use CP/CF in their practice.

All respondents noted that CP/CF use can increase inaccuracies and errors in the notes, from the seemingly innocuous errors (spelling errors) to harmful errors (forgetting to update a note). Information can be outdated yet copied. Errors can be perpetuated. Respondents admitted to forgetting to update information they had previously copied, especially in hectic environments. Some respondents expect that inaccuracies and errors will occur due to the “amount of pressure they feel to get [notes] done” (faculty) and the pressure on providers to see higher volumes of patients.

Whether inaccuracies are accepted as part of the cost of using efficiency tools, these errors can be harmful, in some cases leading to legal as well as patient safety risks. One risk is putting the copied text into the wrong chart, allowing patients to see other patients’ confidential information. Another risk is carrying forward a care management plan that may not be appropriate for patients. One faculty member noted, “whatever we are signing our name [to] should be our own work” (faculty), and that signing off on a note that they have not reviewed thoroughly is problematic.

Respondents noted that plagiarism can be another unintended consequence of using these tools. Attribution was another issue, with respondents discussing how they, or others, copied from other people’s notes without citing where they obtained this information or verifying that the information they copied is correct.

One of the most cited challenges with the CP/CF innovation was the increased length of notes or note bloat. Note bloat makes quickly finding relevant or updated information within a large volume of data more challenging. The length of notes also contributes to the perpetuation of errors. As described by respondents, CP/CF contribute directly to note bloat. Additionally, longer notes mean that providers may not be reviewing and editing notes as carefully as they should, allowing errors to slip through.

Respondents described how the use of CP/CF affected critical thinking skills and led people to not review information thoroughly. Providers, especially medical students and residents/fellow trainees, must learn how to think critically. As one faculty member noted, providers must “separate the wheat from the chaff” (faculty) and determine what to include in a note; critical thinking is an important part of training, which may be impeded by shortcuts in documentation.

The constant friction between the internal and personal desires to practice caution, review information thoroughly, and create concise and accurate notes, and the external pressures of practicing medicine in today’s organizational environment, has led to the most important unanticipated and unintended consequence of the CP/CF innovation: a sense of inner angst, or moral injury, among respondents. The concept of medical moral injury (or distress) among providers has gained traction in the literature in recent years, and covered actions due to commission (providers acting against a belief) or omission (providers not able to act on their beliefs), whether due to a sense of being internally or externally constrained in their ability to provide what they believe is quality care in a high-stakes situation or betrayal from people, institutions, or systems in power [24]. Whether conscious of these feelings of inner angst or moral injury, respondents discussed at length the impact on and of CP/CF use.

Documentation burden, due to time constraints and increased pressure to see higher patient volumes, negatively affected providers’ sense of well-being and created pressure to use these tools, even if they did not want to do so. With a higher patient census, documentation requirements increase, as does the amount of time providers need to review other people’s notes. Due to these conflicting issues, the compromise between efficiency and accuracy is a challenge for providers. Respondents described a love/hate relationship with CP/CF, in that, despite the risks, the tools are necessary to function in the current environment.

Despite the acknowledgement that CP/CF can create some efficiencies, many respondents called CP/CF a “necessary evil” (APP) due to the risks and challenges arising from use.

Respondents experience this internal struggle with wanting to be thorough, efficient, and accurate with documentation, but they do not have enough time to document, so they use tools that they know have errors associated with them, with some calling CP/CF “sloppy and paste” (faculty). Respondents feel this inner angst or moral injury because they have no other choice when the institution is pushing them to see more patients without allocating more time or compensation to document.

Further complicating and adding to the inner angst experienced by providers, the outside environment influences diffusion of an innovation and its consequences (Figure 1). Not only are providers feeling internal pressures, but they are also experiencing outside influences, including legal, regulatory, and financial requirements regarding what content to include in the note. This pressure, and the possible consequences, directly impact how respondents use CP/CF. In one example, a faculty member noted that the Centers for Medicare and Medicaid Services require an enormous number of requirements for one note, with some calling the note the “patient Wiki[pedia]” (faculty) for how many purposes the note serves at one time.

Respondents provided suggestions for improving the EHR infrastructure to increase efficiency, including smart phrases, as well as improving education on EHR use. Part of that education includes understanding what information is relevant to keep in the notes to increase the usefulness of currently available efficiency tools, whether through CP or smart tools (Epic Systems). Respondents also expressed a desire for dictionaries that autocorrect abbreviations or prepopulate problem-based notes.

Another suggestion was for a tool that automatically identifies whether any information had been copied, with author attribution prominently displayed, such as a pop-up alert when using or reviewing text created with CP/CF and requiring users to review common errors from CP/CF, such as dates or values, before closing an encounter. Respondents also mentioned needing alternative tools to display and integrate notes, as well as more standardization and guidelines in note creation. Others suggested having some sections of the notes be collapsible, as well as being able to insert images and hyperlinks within a charting tool for easier access to other areas of the chart.

Some respondents described recent advances in artificial intelligence (AI) and the potential for integration into documentation tools. They wished that the note could be automatically created “like Jarvis style from the Avengers” (faculty). One such advancement currently under investigation is the use of ambient scribes, which listen to the physician-patient encounter and write the notes on behalf of the providers.

As much of the training and communication in EHR use to this point has arisen from informal communication channels (eg, word of mouth) or piecemeal, based on workflows and department needs, respondents requested additional education and training on best practices for documentation. Respondents also suggested training should focus on what the “right tools are to do the work” (APP), which could minimize reliance on CP/CF as the primary documentation tools.

Equally critical to providing training on best practices in documentation is giving providers the amount of time necessary to set up templates and smart phrases in the EHR, as well as an understanding of what is important to include in a note, ensuring documentation is more efficient in the future. Respondents proposed new or updated guidelines and standards with clear teaching and expectations of use for CP/CF to ensure efficient use of the tools. Departmental guidelines and expectations surrounding CP/CF use could help new learners and faculty use these tools appropriately.

The creation of a super user role on teams to facilitate general knowledge-sharing could provide a point person to identify key workflow components and functionality within departments or systems, which could “eliminate the amount of overload that the Epic support team [gets]” (APP) and lessen prolonged waiting times for users.

One of the key barriers to reviewing and editing notes for conciseness and accuracy is time, where “[time spent on editing the notes] is seen as an extra burden” (resident/fellow trainee). This extra time often is uncompensated and means less time caring for patients. The time spent on editing notes has unanticipated consequences of external constraints (eg, reimbursement policies or patient volume targets) on inner angst. An APP noted she wished she could spend more time with patients and less time documenting in general. Another APP highlighted that, “there’s been such an increasing pressure to see more and more patients… and that’s just making it harder and harder to actually document” (APP). With the current documentation culture, one resident/fellow trainee noted that, “the only way to function really, is to be copy and pasting from yourself [and] from others” (resident/fellow trainee).

Providers argued that there needs to be a cultural shift with regard to best practices for what gets documented and put into the note, as well as how notes are used. The reliance on notes as a patient “Wikipedia” has contributed to note bloat and the rise in errors and inaccuracies, as well as provider burnout, and therefore, reliance on CP/CF to document quickly. Providing the time needed for reviewing the work is critical.

Some providers suggested that the use of these tools should be limited. One faculty member said attribution should be mandatory; others added that the copied portions should be cited in quotes and attributed to the original author as in peer-reviewed publications. It could also be helpful to use different fonts, italics, or bold typeface to indicate copied text. Others mentioned that CP/CF should only be used for what is necessary to contextualize or augment the note, with clear identification of the information’s source.

Awareness of CP/CF tools spread by word of mouth (Figure 1). As reported by others, the diffusers (ie, the ones spreading the innovation) are sometimes residents/fellow trainees and APPs, rather than supervisory or more senior staff, a trend that has persisted over the years [8,20,21,25]. However, simple awareness does not guarantee the quality of the information communicated in the medical note, so tailored formal training is recommended [26,27]. Another recommendation to promote high-quality training is to have an EHR champion available, especially in the inpatient setting where CP/CF are most used [8,20,27,28].

Communication and training about the use of CP/CF in documentation can provide teaching opportunities to enhance critical thinking of relevant information to capture [29]. This may be less likely in high-pressure, dynamic systems, but some have had success in training through templated or team-based writing [29,30].

Innovations (Figure 1) such as CP/CF are highly complex and are integrated into similarly complex and evolving systems [22,31,32]. Implementation and adoption rely not only on individuals and their personal characteristics, but the innovation itself, as well as the structure and characteristics, and culture of the organization in which the innovation is deployed. By certain metrics, innovations may be successfully diffused (technically adopted), but a lack of consideration for the interdependency of the actors in a system may inhibit realization of the optimal or true value to the system, and can lead to unintended consequences [31,32].

Our results reflect those of other reports that CP/CF improve efficiency [6], continuity of care for patients [8], and communication with teammates [33], as well as decreased documentation burden [7]. Yet in the two decades of literature acknowledging the benefit of innovation in electronic records, these same reports highlight the double-edged sword of efficiency versus unintended consequences [8,34]. Without trust in the system or other users, or without bulwarks against our own inherent flaws as human users of technology [35], the optimal use and benefits of these innovations and the intended consequence of improving quality of care will not be realized [31].

Our respondents describe the need for short-term solutions, such as recurring formal training on how and when to use CP/CF. Others have similarly demonstrated that lack of knowledge of appropriate use results in increased length of notes [36] and the importance of training and education for safe practice regarding these tools [31].

Documentation burden, note bloat, inaccuracies, and more time spent documenting to the detriment of patient care, training, and interpersonal communication and trust—all have led to a perceived worsening of culture, the work environment, and workflows [5,37]. These phenomena are not new; the same benefits and challenges have remained consistent over time and across systems [38-40]. This dichotomy of intended (often positive) consequences and unintended (often negative) consequences results in providers experiencing increased inner angst and moral injury [41,42]. Providers report angst from constraints against practicing what they consider “quality” care, and despite knowing the myriad risks, use tools such as CP/CF as the only workaround right now in a broken system, calling CP/CF a necessary evil. While providers acknowledge that CP/CF and other tools aid in the continuity of care and create a sense of efficiency when documenting, the lack of time to review notes thoroughly is a consistent and pervasive structural barrier. In such instances, errors slip through the cracks—the role of CP/CF in errors, inaccuracies, and outdated information is of particular concern [6,12], as they have contributed to note bloat [5,8] and may play a role in patient safety [16]. Inaccuracies may damage a patient’s trust in and experience with the clinician or system; contribute to diagnostic and safety errors (inaccurate or out-of-date records, difficulty in finding relevant data in bloated notes); and increase legal risks, including unintentional falsification of records or plagiarism and medical malpractice [16,17]. All of these factors conspire to reduce providers’ overall perceived quality of care delivery. This, in turn, can further worsen provider dissatisfaction and burnout, with a study suggesting that clinician involvement in medical errors is an independent risk of burnout [43].

The outer system (Figure 1) is a key factor for optimal diffusion and implementation of an innovation [32,39]. Recommendations to address challenges in using CP/CF include developing policies, both institution-wide and specialty-specific, for CP/CF use. These larger structural factors—policies, standards, legislation, system resources, and engagement of leadership—filter down into organizational workflow and processes and then to individual knowledge of the innovation [32,39,40]. Although improvements at this larger scale are difficult to accomplish and are often more long-term solutions, a fundamental shift is needed at the outer system level in how these innovations are built for and integrated into dynamic, complex systems. Notes should serve clinical purposes and not focus as much on reimbursement regulations and national quality measures [21,32,44].

In the short term, most providers report the need for specific interventions, such as training to improve optimal EHR use, continued EHR optimization, and improved awareness of best practices for use of the functionality are necessary. Others recommended some degree of restrictions on use as well. While shown in other health systems to have direct impacts on hospital readmission [45], the overall widespread reliance on its use, and the inability to remove this functionality (easily) from underlying operating systems, suggest this is a nonviable solution. As a result, one must look for more novel, sustainable solutions. With the growth of AI and tools such as ambient or digital scribes already in use in clinical care to reduce documentation burden, careful reflection on the appropriate use of innovative tools will be paramount in mitigating current and future unintended consequences [6,13,46-48]. Another way to mitigate unintended consequences for ambient scribing would be to develop measures and metrics of success (eg, provider satisfaction scores, decrease in pajama time charting, decrease in documentation time, and increase in work/life balance). That way, organizations could evaluate whether the ambient scribes are aiding providers related to the intended metrics. However, while ambient scribes hold promise, to date, no studies have documented the impact of the ambient scribes on the amount of CP present in notes. This is likely, in part, because studies on ambient scribes are limited to ambulatory settings [49]. This will need to be an area of future study as the technology becomes more widespread.