Documentation Burden Research Articles

Implementing Digital Scribes to Reduce Electronic Health Record Documentation Burden Among Cancer Care Clinicians: A Mixed-Methods Pilot Study

To address shortcomings of human scribes (eg, turnover), clinicians are considering digital scribes (DSs). To our knowledge, to date, no study has assessed DS implementation or clinician user experience in cancer centers. We assessed the DS's feasibility, acceptability, appropriateness, usability and its preliminary association on clinician well-being in a cancer center. We also identified implementation facilitators and barriers to DS use. Using a mixed-methods longitudinal pilot study design, we implemented a DS at a cancer center. Data collection included surveys at baseline and 1 month after DS use and a semistructured interview with clinicians. The survey assessed demographics, Mini Z (workplace stress and burnout), sleep quality, and implementation outcomes (feasibility, acceptability, appropriateness, and usability). The interview assessed how the DS was used and its impacts on workflows and recommendations for future implementations of the DS. We used paired t tests to assess differences in Mini Z and sleep quality measures over time. Across nine survey responses and eight interviews, we found that although feasibility scores were slightly lower than our cutoff point (15.2 v 16.0), clinicians rated the DS as marginally acceptable (16.0) and appropriate (16.3). Usability was considered marginally usable (68.6 v 68.0). Although the DS did not significantly improve burnout (3.6 v 3.9, P = .081), it improved perceptions of having sufficient documentation time (2.1 v 3.6, P = .005). Clinicians identified suggestions for future implementations, including training needs and usability improvements. Our preliminary findings suggest that DS implementation is marginally acceptable, appropriate, and usable among cancer care clinicians. Individualized training and on-site support may improve implementation.

Scoping review: Positive and negative impact of technology on clinicians

BackgroundUnnecessary electronic health record (EHRs) documentation burden and usability issues have negatively impacted clinician well-being (e.g., burnout and moral distress). PurposeThis scoping review was conducted by members from three expert panels of the American Academy of Nurses to generate consensus on the evidence of both positive and negative impact of EHRs on clinicians. MethodsThe scoping review was conducted based on Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Extension for Scoping Reviews guidelines. ResultsThe scoping review captured 1,886 publications screened against title and abstract 1,431 excluded, examined 448 in a full-text review, excluded 347 with 101 studies informing the final review. DiscussionFindings suggest few studies that have explored the positive impact of EHRs and more studies that have explored the clinician's satisfaction and work burden. Significant gaps were identified in associating distress to use of EHRs and minimal studies on EHRs’ impact on nurses. ConclusionExamined the evidence of HIT's positive and negative impacts on clinician's practice, clinicians work environment, and if psychological impact differed among clinicians.

Paving the Road for Chimeric Antigen Receptor T Cells: American Society for Transplantation and Cellular Therapy 80/20 Task Force Consensus on Challenges and Solutions to Improving Efficiency of Clinical Center Certification and Maintenance of Operations for Commercially Approved Immune Effector Cell Therapies

As the number and type of regulatory authority-approved cellular therapies grow, clinical treatment centers face a heavy burden of duplicative documentation around initial qualification, ongoing auditing, and reporting, with overlapping requirements from each manufacturer to ensure safe use of their specific product, which in the United States are stipulated under individual Food and Drug Administration (FDA) Biologic License Applications. The American Society for Transplantation and Cellular Therapy (ASTCT) convened the 80/20 Task Force to consider challenges and potential solutions to these issues. The Task Force proposed that 80% of manufacturers' requirements for onboarding and ongoing operations of commercially available products could be standardized and streamlined. Task Force members interviewed dozens of stakeholders, including clinicians at large academic medical centers already using commercial and investigational immune effector cell (IEC) products, regulators, members of accrediting bodies and professional cellular therapy societies, and manufacturers of IEC therapies for oncologic indications. In November 2021, the Task Force organized and led virtual discussions in a public forum and at a private ASTCT 80/20 Workshop at the online AcCELLerate Forum, a cellular-therapy stakeholders' meeting organized by the ASTCT, National Marrow Donor Program (NMDP), and Center for International Blood and Marrow Transplant Research (CIBMTR). At the workshop, approximately 60 stakeholders worked to identify and prioritize common challenges in onboarding and maintenance of operations at clinical sites for commercial FDA-approved and future IEC therapies and ways to streamline the process. It was agreed that standardization would improve efficiency of onboarding, allowing more cost-effective, sustainable growth of approved IEC therapies at treatment centers, and facilitate wider access while maintaining safety and clinical success. This early but extensive survey of stakeholders resulted in 5 overarching suggestions for both established and emerging treatment centers: (1) eliminate duplication in accreditation and auditing of clinical sites; (2) define expectations for the education about and management of CAR-T therapy toxicities to potentially replace product-specific REMS programs; (3) streamline current REMS education, testing, and data reporting; (4) standardize information technology (IT) platforms supporting enrollment, clinical site-manufacturer communication, and logistics of maintaining chain of identity/chain of custody across multiple transportation steps; and (5) encourage the use of universal nomenclature by cell therapy manufacturers. Future discussions need to engage a broader range of stakeholders, including administrators, pharmacists, nurses, data coordinators, surgeons, pathologists, and those developing promising cellular therapies for solid tumors, as well as teams from smaller academic or community cancer center settings. Continued collaboration with stakeholders outside of clinical sites will include accrediting bodies/auditors, established and emerging cell therapy companies, software developers, professional societies, and the patients who receive these therapies. Active dialog with government regulators remains essential. Such joint efforts are critical as the number of IEC therapies for myriad oncologic and nononcologic indications grows.

A qualitative study of the dark and bright sides of physicians' electronic health record work outside work hours.

The introduction of electronic health records (EHRs) has contributed considerably to EHR work outside work (WOW) hours for physicians. Prior research has identified the pressures associated with stress resulting from EHR WOW, yet developing a nuanced understanding of how physicians appraise and respond to this stress, and the resulting impacts, remains absent from the literature. Grounded in the technostress model, this study takes a qualitative approach to explore both the pressures and opportunities associated with EHR WOW. Thematic analysis of data from semistructured interviews was utilized to examine the pressures and opportunities associated with EHR WOW among primary care pediatricians (n = 15) affiliated with a large Midwestern pediatric health system. The physicians in this study regularly spent time working in the EHR outside work hours. They felt the EHR contributed to their documentation burden, which ultimately increased their EHR WOW, and reported a sense of burden from ubiquitous EHR availability. Conversely, they appreciated the flexibility the EHR provided in terms of work-life balance. Suggestions for improvement under the direct purview of practice management included enhanced EHR usability, improvements in workflow during work hours to free up time to document, and more training on both EHR documentation strategies and ongoing software upgrades. Physicians perceive that the EHR exerts certain pressures while affording new opportunities and conveniences. This study provides evidence of both the pressures and opportunities of EHR WOW and their effect on physician well-being. Specific opportunities are identified for health administrators to enable physicians to better manage EHR WOW.

Reflections on the Documentation Burden Reduction AMIA Plenary Session through the Lens of 25 × 5.

Documentation burden, defined as the excessive effort expended on healthcare documentation, is associated with a number of adverse outcomes, including clinician burnout, reduced quality of medical care, and disruption of clinical data contained in the electronic health record.[1] With the growing concern for the wellness of the clinical workforce, documentation burden is receiving national attention. The American Medical Informatics Association (AMIA) has taken the lead by establishing the 25 x 5 Task Force ("Task Force") in December 2021, which aims to reduce clinician documentation burden to 25% of the current state in the coming 5 years. [2] Aligned with the timing of the Task Force launch, the AMIA Clinical Informatics Conference (CIC) 2022 co-chairs, Rosemary Kennedy (Connect America) and Paul Fu (City of Hope), conceptualized an opening plenary panel in a 'fireside chat' format focused on clinical documentation burden.[3] In this editorial, the authors describe the panel discussion, identify key themes from the panel, and offer recommendations to address documentation burden. The proceedings of the AMIA CIC 2022 Fireside Chat serve as an opportunity to acknowledge those who are engaged and passionate about addressing documentation burden from the vantage point of different stakeholders and institutions.

Perceptions of Facilitators and Barriers to Smoking Cessation Among Patients and Providers in a Cancer Center: A Single Institution Qualitative Exploratory Study.

Cancer patients who remain tobacco users have poorer outcomes, including increased mortality and decreased treatment tolerance; however, cessation post-diagnosis is challenging. Our formative research explored cessation-related perspectives among patients and staff at one National Cancer Institute-designated cancer center, to inform improving cessation services within oncology care. Using a descriptive phenomenological approach, a purposive sample of current cancer patients (n = 13) and cancer center physicians and cessation program staff (n = 9) were recruited to complete one-on-one audio-recorded in-depth qualitative interviews, to explore experiences providing or receiving cessation support, and perspectives on patients' readiness and needs regarding cessation. Thematic coding utilized Green's predisposing, enabling, and reinforcing framework to identify factors having positive, negative, or mixed impact on delivery of best-practices cessation services (ie, 5As) and patient cessation success. Patients identified cancer diagnosis as a wake-up call, existing health problems, persistent healthcare providers, cost of cigarettes, and societal disapproval of smoking as factors facilitating quitting. Futility of quitting after a cancer diagnosis, cost and logistics of program participation, clinician time constraints, and lifetime addiction made quitting harder. Family, friends, stigma and motivation, and pharmacotherapies played mixed roles. Patients felt survivor-focused cessation programs, including stress management, could better enable quitting. Provider-anticipated problems with implementing cessation counseling included so-called "therapeutic nihilism" (ie, pessimism regarding cessation post-diagnosis), lack of training and standardized approaches, and time and documentation burden. Clinicians saw both policies and peer clinician "champions" as potentially increasing prioritization of cessation within oncology. Findings highlight unmet needs for patients and providers regarding provision of effective cessation care. Despite survival benefit, cessation is still not standard within cancer care. Our results show that many patients would benefit from standardized programs where they are routinely asked about cessation. Providers would benefit from both structural enhancements and professional education to ensure that evidence-based cessation services tailored to cancer patients, are offered throughout treatment and survivorship.

Using less keystrokes to achieve high top-1 accuracy in Chinese clinical text entry.

As a routine task, physicians spend substantial time and keystrokes on text entry. Documentation burden is increasingly associated with physician burnout. Predicting at top-1 with less keystrokes (TLKs) is a hot topic for smart text entry. In Western countries, contextual autocomplete is deployed to alleviate the burden. Chinese text entry is intercepted by input method engines (IMEs), which cut off suggestions from electronic health records (EHRs). To explore a user-friendly approach to make text entry easier and faster for Chinese physicians. Physicians were shadowed to uncover the real-word input behaviors. System logs were collected for behavior validation and then used for context-based learning. An in-line web-based popup layer was proposed to hold the best suggestion from EHRs. Keystrokes per character and TLK rate were evaluated quantitatively. Questionnaires were used for qualitative assessment. Nine hundred fifty-two physicians were enrolled in a field testing. 14 facilitators and 17 barriers related to IMEs were identified after shadowing. With system logs, physicians tended to split long words into short units, which were 1-4 in length. 81.7% of these units were disyllables. Compared to the control group, the intervention group improved TLK rate by 40.3% (p < .0001), and reduced keystrokes per character by 48.3% (p < .0001). Survey results also promised positive feedback from physicians. Keystroke burden and frequent choice reaction time challenge Chinese physicians for text entry. The proposed system demonstrates an approach to alleviate the burden. Contextual information is easily retrieved and it further helps improve the top-1 accuracy, with a smaller number of keystrokes. While positive feedback is received, it promises a benefit to protect patient privacy.

Burnout Related to Electronic Health Record Use in Primary Care.

Physician burnout has been increasing in the United States, especially in primary care, and the use of Electronic Health Records (EHRs) is a prominent contributor. This review article summarizes findings from a PubMed literature search that shows the significant contributors to EHR-related burnout may be documentation and clerical burdens, complex usability, electronic messaging and inbox, cognitive load, and time demands. Documentation requirements have escalated and have inherently changed from paper-based records. Many clerical tasks have also shifted to become additional physician responsibilities. When considering factors of efficiency, effectiveness, and user satisfaction, EHRs overall have an inferior usability score when compared to other technologies. The volume and organization of data along with alerts and complex interfaces require a substantial cognitive load and result in cognitive fatigue. Patient interactions and work-life balances are negatively affected by the time requirements of EHR tasks during and after clinic hours. Patient portals and EHR messaging have created a separate source of patient care outside of face-to-face visits that is often unaccounted productivity and not reimbursable.

An Organization's Documentation Burden Reduction Initiative: A Quality Improvement Project

An Organization's Documentation Burden Reduction Initiative: A Quality Improvement Project

THE ASSOCIATION BETWEEN NURSING HOME IT MATURITY AND UTIS AMONG LONG-TERM NH RESIDENTS

Abstract Prof. Alexander will present a study linking national nursing home (NH) health information technology (HIT) to quality. This research explores relationships between NH HIT maturity and UTIs examined during a repeated cross-sectional study over 4 consecutive years (2013-2017). HIT maturity represents the diversity of technology use in NHs. Researchers conducted bivariate and multivariate regressions using MDS 3.0 resident assessments and post stratified survey weights controlling for NH characteristics. Our sample included 816 NHs. These NHs had 219,730 regular NH resident assessments within 90 days of a survey, representing 80,322 unique NH residents. Of these assessments, 4.1% recorded a UTI. In the multivariate analyses, administrative HIT capabilities was associated with lower odds of UTI (AOR: 0.906, 95% CI: 0.843, 0.973), controlling for covariates. Integration of administrative HIT systems may relieve the burden of tracing UTIs, data documentation and record retrieval affording NH staff time to focus their efforts on clinical care.

It's time to change our documentation philosophy: writing better neurology notes without the burnout.

Succinct clinical documentation is vital to effective twenty-first-century healthcare. Recent changes in outpatient and inpatient evaluation and management (E/M) guidelines have allowed neurology practices to make changes that reduce the documentation burden and enhance clinical note usability. Despite favorable changes in E/M guidelines, some neurology practices have not moved quickly to change their documentation philosophy. We argue in favor of changes in the design, structure, and implementation of clinical notes that make them shorter yet still information-rich. A move from physician-centric to team documentation can reduce work for physicians. Changing the documentation philosophy from "bigger is better" to "short but sweet" can reduce the documentation burden, streamline the writing and reading of clinical notes, and enhance their utility for medical decision-making, patient education, medical education, and clinical research. We believe that these changes can favorably affect physician well-being without adversely affecting reimbursement.

Promote Community Engagement in Participatory Research for Improving Breast Cancer Prevention: The P.I.N.K. Study Framework

Breast cancer (BC) has overtaken lung cancer as the most common cancer in the world and the projected incidence rates show a further increase. Early detection through population screening remains the cornerstone of BC control, but a progressive change from early diagnosis only-based to a personalized preventive and risk-reducing approach is widely debated. Risk-stratification models, which also include personal lifestyle risk factors, are under evaluation, although the documentation burden to gather population-based data is relevant and traditional data collection methods show some limitations. This paper provides the preliminary results from the analysis of clinical data provided by radiologists and lifestyle data collected using self-administered questionnaires from 5601 post-menopausal women. The weight of the combinations of women's personal features and lifestyle habits on the BC risk were estimated by combining a model-driven and a data-driven approach to analysis. The weight of each factor on cancer occurrence was assessed using a logistic model. Additionally, communities of women sharing common features were identified and combined in risk profiles using social network analysis techniques. Our results suggest that preventive programs focused on increasing physical activity should be widely promoted, in particular among the oldest women. Additionally, current findings suggest that pregnancy, breast-feeding, salt limitation, and oral contraception use could have different effects on cancer risk, based on the overall woman's risk profile. To overcome the limitations of our data, this work also introduces a mobile health tool, the Dress-PINK, designed to collect real patients' data in an innovative way for improving women's response rate, data accuracy, and completeness as well as the timeliness of data availability. Finally, the tool provides tailored prevention messages to promote critical consciousness, critical thinking, and increased health literacy among the general population.

Physician Note Composition Patterns and Time on the EHR Across Specialty Types: a National, Cross-sectional Study.

The burden of clinical documentation in electronic health records (EHRs) has been associated with physician burnout. Numerous tools (e.g., note templates and dictation services) exist to ease documentation burden, but little evidence exists regarding how physicians use these tools in combination and the degree to which these strategies correlate with reduced time spent on documentation. To characterize EHR note composition strategies, how these strategies differ in time spent on notes and the EHR, and their distribution across specialty types. Secondary analysis of physician-level measures of note composition and EHR use derived from Epic Systems' Signal data warehouse. We used k-means clustering to identify documentation strategies, and ordinary least squares regression to analyze the relationship between documentation strategies and physician time spent in the EHR, on notes, and outside scheduled hours. A total of 215,207 US-based ambulatory physicians using the Epic EHR between September 2020 and May 2021. Percent of note text derived from each of five documentation tools: SmartTools, copy/paste, manual text, NoteWriter, and voice recognition and transcription; average total and after-hours EHR time per visit; average time on notes per visit. Six distinct note composition strategies emerged in cluster analyses. The most common strategy was predominant SmartTools use (n=89,718). In adjusted analyses, physicians using primarily transcription and dictation (n=15,928) spent less time on notes than physicians with predominant Smart Tool use. (b=-1.30, 95% CI=-1.62, -0.99, p<0.001; average 4.8 min per visit), while those using mostly copy/paste (n=23,426) spent more time on notes (b=2.38, 95% CI=1.92, 2.84, p<0.001; average 13.1 min per visit). Physicians' note composition strategies have implications for both time in notes and after-hours EHR use, suggesting that how physicians use EHR-based documentation tools can be a key lever for institutions investing in EHR tools and training to reduce documentation time and alleviate EHR-associated burden.

Merit-based incentive payment system participation and after-hours documentation among US office-based physicians: Findings from the 2021 National Electronic Health Records Survey.

After-hours documentation burden among USclinicians is often uncompensated work and has been associated with burnout, leading health systems to identify root causes and seek interventions to reduce this. A few studies have suggested quality programmeparticipation (e.g., Merit-Based Incentive Payment System [MIPS]) was associated with a higher administrative burden. However, the association between MIPS participation and after-hours documentation has not been fully explored. Thus, this study aims to assess whether participation in the MIPS programme was independently associated with after-hours documentation burden. We used 2021 data from the National Electronic Health Records Survey. We used a multivariable ordinal logistic regression model to assess whether MIPS participation was associated with the amount of after-hours documentation burden when controlling for other factors. We controlled for physician age, specialty, sex, number of practice locations, number of physicians, practice ownership, whether team support (e.g., scribes) is used for documentation tasks, and whether the practice accepts Medicaid patients. We included 1801 office-based US physician respondents with complete data for variables of interest. After controlling for other factors, MIPS participation was associated with greater odds of spending a greater number of hours on after-hours documentation (odds ratio = 1.44, 95% confidence interval 1.06-1.95). MIPS participation may increase after-hours documentation burden among USoffice-based physicians, suggesting that physicians may require additional resources to more efficiently report data.

Documentation dynamics: Note composition, burden, and physician efficiency.

To analyze how physician clinical note length and composition relate to electronic health record (EHR)-based measures of burden and efficiency that have been tied to burnout. Secondary EHR use metadata capturing physician-level measures from 203,728 US-based ambulatory physicians using the Epic Systems EHR between September 2020 and May 2021. In this cross-sectional study, we analyzed physician clinical note length and note composition (e.g., content from manual or templated text). Our primary outcomes were three time-based measures of EHR burden (time writing EHR notes, time in the EHR after-hours, and EHR time on unscheduled days), and one measure of efficiency (percent of visits closed in the same day). We used multivariate regression to estimate the relationship between our outcomes and note length and composition. Physician-week measures of EHR usage were extracted from Epic's Signal platform used for measuring provider EHR efficiency. We calculated physician-level averages for our measures of interest and assigned physicians to overall note length deciles and note composition deciles from six sources, including templated text, manual text, and copy/paste text. Physicians in the top decile of note length demonstrated greater burden and lower efficiency than the median physician, spending 39% more time in the EHR after hours (p< 0.001) and closing 5.6 percentage points fewer visits on the same day (p< 0.001). Copy/paste demonstrated a similar dose/response relationship, with top-decile copy/paste users closing 6.8 percentage points fewer visits on the same day (p< 0.001) and spending more time in the EHR after hours and on days off (both p< 0.001). Templated text (e.g., Epic's SmartTools) demonstrated a non-linear relationship with burden and efficiency, with very low and very high levels of use associated with increased EHR burden and decreased efficiency. "Efficiency tools" like copy/paste and templated text meant to reduce documentation burden and increase provider efficiency may have limited efficacy.

Decreasing the Nursing Documentation Burden During the Covid-19 Surge

During the Covid-19 pandemic, nurses requested a clean, streamlined, intuitive view of the adult nursing assessment(s) within the electronic medical record (EMR). We created a more efficient method during a national disaster to reduce duplicative efforts and allow additional time with patients. This project was added as part of the Clinically Led EMR Optimization (CLEO) strategy to eliminate unnecessary EMR assessment data elements in the adult medical-surgical and critical care areas. This was completed in a 5-month period and decreased 20% of the data points entered by nursing. 433 data points were excluded or relocated to achieve the desired result.

No Longer Beholden – Moving On from Elaborate Chart Notes

Despite recent changes in Medicare billing documentation guidelines, physician chart notes remain far lengthier and more detailed than is required. This is worrisome, as documentation burden is a major contributor to physician burnout. Elements of medical culture which have contributed to the elaborate chart note standard may be used to transform notes, reduce charting burden and improve physician well-being.

Documentation Burden in Nursing and Its Role in Clinician Burnout Syndrome.

The purpose of this study is to understand the relationship between documentation burden and clinician burnout syndrome in nurses working in direct patient care. The Office of the National Coordinator considers documentation burden a high priority problem. However, the presence of documentation burden in nurses working in direct patient care is not well known. Furthermore, the presence of documentation burden has not been linked to the development of clinician burnout syndrome. This paper reports that the results of a cross-sectional survey study comprised of three tools: (1) The burden of documentation for nurses and mid-wives survey, (2) the system usability scale, and (3) Maslach's burnout inventory for medical professionals. Documentation burden has a weak to moderate correlation to clinician burnout syndrome. Furthermore, poor usability of the electronic health record (EHR) is also associated with documentation burden and clinician burnout syndrome. This study suggests that there is a relationship between documentation burden and clinician burnout syndrome. The correlation of poor usability and domains of clinician burnout syndrome implies the need for more work on improving the usability of EHR for nursing documentation. Further study regarding the presence of documentation burden and its correlation to clinician burnout syndrome should focus on specific areas of nursing to understand the drivers of documentation burden variation within and across specialty domains.

Identifying sources of burnout among clinicians at a cancer center: A qualitative analysis.

429 Background: Clinician burnout leads to increased job turnover and workforce shortages, and reduced patient satisfaction and quality of care. Despite its importance, there has been limited study of burnout among the cancer care workforce including sources of burnout. This information can be used to inform intervention design for use in the cancer care setting specifically. To address this gap, we analyzed open-ended responses to a well-being survey administered to clinicians (physicians and advanced practice providers) at a Cancer Center. Methods: In February 2022, we electronically administered the American Medical Association’s clinician well-being survey to all practicing clinicians at a National Cancer Institute-designated Comprehensive Cancer Center in Florida. Of 700 clinicians, 405 (58%) responded. Of the respondents, 259 (64.0%) answered the free-text question “Tell us more about your stressors and what we can do to minimize them.” We used in-vivo coding to develop qualitative themes across responses. If a given response incorporated multiple themes, we coded the response under all pertinent themes. Results: A majority (76/259) of respondents commented on staffing issues, such as their clinics being understaffed or the quality of current staff. Another frequent theme (64/259) was the electronic health records (EHR) system, such as lack of integration between modules, inbox fatigue, alert fatigue, and inefficient documentation review processes. Respondents also reported scheduling issues as a pain point (56/259), such as having schedules that do not reflect actual clinical practice, being overbooked, and scheduling errors. Documentation burden was also highlighted as an issue across respondents (34/259). Documentation was considered tedious and some respondents reported a mismatch between available documentation tools in the EHR and actual documentation needs. Less common themes reported across respondents included design issues of facility space (e.g., no dedicated workspace to complete work without interruptions) and insufficient time to complete administrative, research, and documentation requirements. Conclusions: Our findings suggest that interventions that optimize staffing models, EHR processes (e.g., documentation), and scheduling practices may reduce burnout for a considerable number of cancer care clinicians.

O50 - Being with computer: Midwives’ perspectives of the impact of the electronic maternity record on their practice providing woman-centred care

Increasingly midwives are using digital technology in place of handheld records to record and document midwifery care across the continuum of care in both community and hospital settings. A rationale for this change has been the purported benefits of electronic health records (EHR) in reducing errors of omission, duplication, transcription, and interpretation that are caused by unclear, illegible, absent, and lost information. However, both positive and negative features of EHRs have been reported by clinicians. The objectives of this study were to explore midwives’ experiences using the integrated electronic maternity record (EMR) and their perspectives on the impact of EMR on midwifery practice and the provision of woman-centred care. We conducted a thematic analysis of semi-structured interviews with 15 midwives across two Australian tertiary public hospitals. Participating midwives cared for women across the pregnancy continuum. Midwives practiced in caseload models of care (3) and core hospital models of care (12). Midwives described a significant increase to the documentation burden since the transition from paper to EMR. An overarching theme of reconciling being with woman while being with computer emerged. Midwives described how their professional identity, embedded in their ability to be intimately present with the labouring woman, conflicted with medico-legal requirements of contemporaneous documentation and practicalities, such as the location of the computers. Midwives negotiated these competing demands to keep the woman at the centre of care. The lack of functionality of the EMR led to workflow inefficiencies, workplace tension and loss of job satisfaction. Midwives are focussed on being ‘with woman’ and providing woman-centred care while at the same time fulfilling their professional obligations of documentation. Midwives are well placed to make recommendations on the functionality of the EMR. Translating these findings to practice and education could lead to system improvements.