Exploring Physicians’ Dual Perspectives on the Transition From Free Text to Structured and Standardized Documentation Practices: Interview and Participant Observational Study

BACKGROUND: Clinical documentation plays a crucial role in providing and coordinating care. Despite the widespread adoption of electronic health record (EHR) systems, many end users still document clinical data in a manner similar to traditional paper-based records. To fully leverage the benefits of EHR systems, it is necessary to adopt new documentation approaches that facilitate easy access to information at the point of care and seamless exchange of information across health care facilities. OBJECTIVE: We aimed to evaluate how the transition from an older EHR system to a cross-institutional EHR system impacts physicians' documentation practices and gain a deeper understanding of the factors influencing their choice between free text and structured and standardized documentation methods. METHODS: A qualitative study was conducted between September 2023 and January 2024. It involved participant observations and individual semistructured interviews with physicians at a university hospital in Norway. Data were analyzed using reflexive thematic analysis. RESULTS: The analysis revealed 3 main themes. First, physicians encountered challenges during the implementation phase of the new EHR system due to its complexity and their unfamiliarity with its use. However, with time, physicians gradually adopted new documentation processes. This integration or adoption primarily occurred by learning through practical experience and collaborative knowledge exchange with their peers. Second, although the implementation of the new EHR system had increased structured and standardized clinical documentation, free text remained the preferred method, with some exceptions. In addition, the fact that many physicians still relied on free-text documentation created a sense of distrust among them toward some of the standardized clinical data. Finally, the informants had mixed perceptions of Systematized Nomenclature of Medicine-Clinical Terms. Some viewed it as a more nuanced terminology system, while others found it more complex. Most informants found using templates for routine procedures beneficial as it saved time in the documentation process and ensured that all necessary parameters and documentation requirements were met. CONCLUSIONS: The study findings revealed that physicians' acceptance of new documentation processes is influenced by various social and technological factors. These factors include previous documentation experiences, perceived benefits, familiarity with the EHR system, time constraints, and user-friendliness of the system. While physicians generally have a positive attitude toward using templates for routine procedures, they often create their own templates, and data within these templates are documented in a free-text format. To address this, health care organizations should consider implementing common standardized or semistandardized templates to reduce disparities in documentation, enhance data recording, and ensure adherence to guidelines. Furthermore, to facilitate the transition to the new documentation processes, we recommend providing physicians with customized training programs and platforms for tacit knowledge exchange.

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