Example 7: Paper Persistence After EHR Implementation

Issues Encountered

The Computerized Patient Record System (CPRS) is implemented throughout the Veterans Affairs Medical system. A recent study indicated that clinicians in the VA system consistently use paper to work around the limitations of CPRS. Some examples of the workarounds they identified include:

  1. An emergency department physician feels that a paper form is more efficient than CPOE. He passes his paper-based orders to the nurse, who passes them off to the clerk, who then enters the order into the computer.
  2. A pharmacist makes handwritten notes on printouts from the EHR and then enters the handwritten data back into the system later in the day. The pharmacist said, "The hand notes help me remember. I do this for discharges and inpatients. There can be 6 to 12 discharges per day. It is not possible to make these types of notes in CPRS [in real time]. I don't know how you would do this in the computer... We need paper to do our job."
  3. A nurse uses a notebook to track patient lab values: "I add important footnotes — anytime the [international normalized ratio] INR is too high... The primary care provider will think the INR was too high only this one time but I have the data in my notebook to show that it was too high three times."

Finding a Solution

An EHR has many advantages over the paper record, including improved legibility, remote access, and the ability to integrate across information systems. However, don't be surprised if the EHR does not replace paper use entirely. Paper use may continue to the extent that clinicians perceive that it is more efficient than using the EHR.

How to best deal with the persistence of the paper record is still an open problem. However, the VA is carefully studying when, where, and why clinical users would develop these paper-based information tools to supplement or work around the EHR. They then use their observations to determine how the EHR applications could be altered to better suit the clinical users' work.

In some instances, paper-based solutions may be more efficient than a difficult-to-use EHR. However, these workarounds can create unanticipated risks or negate many of the benefits of having an EHR. If modifying the EHR to better suit the clinicians' work processes is not feasible, it might be most effective to develop standardized paper-based tools that can be used throughout your organization to supplement the EHR. While this solution may not be ideal, it is likely preferable to several different ad-hoc approaches floating around.

Lesson Learned: 
  • Paper-based supplementation and workarounds are very common.
  • Administrators should seek to find out why clinicians find paper records desirable and try to determine how the EHR could be modified to better suit clinical work so as to reduce the need for paper.
  • In some instances, user preference for paper may be very strong. In these circumstances, it may be preferable to use both paper and electronic systems; approved paper systems should be standardized to avoid inconsistencies across the organization.

Saleem JJ, Russ AL, Justice CF,et al. Exploring the persistence of paper with the electronic health record. Int J Med Inform. 2009 Sep; 78(9): 618-28.

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