Exploring the persistence of paper with the electronic health record

https://doi.org/10.1016/j.ijmedinf.2009.04.001Get rights and content

Abstract

Objective

Healthcare organizations are increasingly implementing electronic health records (EHRs) and other related health information technology (IT). Even in institutions which have long adopted these computerized systems, employees continue to rely on paper to complete their work. The objective of this study was to explore and understand human-technology integration factors that may be causing employees to rely on paper alternatives to the EHR.

Methods

We conducted semi-structured interviews with 20 key-informants in a large Veterans Affairs Medical Center (VAMC), with a fully implemented EHR, to understand the use of paper-based alternatives. Participants included clinicians, administrators, and IT specialists across several service areas in the medical center.

Results

We found 11 distinct categories of paper-based workarounds to the use of the EHR. Paper use related to the following: (1) efficiency; (2) knowledge/skill/ease of use; (3) memory; (4) sensorimotor preferences; (5) awareness; (6) task specificity; (7) task complexity; (8) data organization; (9) longitudinal data processes; (10) trust; and (11) security. We define each of these and provide examples that demonstrate how these categories promoted paper use in spite of a fully implemented EHR.

Conclusions

In several cases, paper served as an important tool and assisted healthcare employees in their work. In other cases, paper use circumvented the intended EHR design, introduced potential gaps in documentation, and generated possible paths to medical error. We discuss implications of these findings for EHR design and implementation.

Introduction

When optimally implemented, electronic health records (EHRs) hold tremendous potential benefit for healthcare systems and can enhance how patient data are documented and organized. EHRs provide improved legibility of patient data; simultaneous, remote access; and integration with other information sources [1]. While some of the potential benefits of EHRs are well-known, they do not produce completely “paperless” processes. Previous research described the phenomenon of “paper-persistence” for medical ordering processes in healthcare organizations where computerized provider order entry (CPOE) was implemented [2], [3], [4]. CPOE is only one potential component of many integrated clinical applications in EHRs, and so while implementation of CPOE does not eliminate all paper, even if the paper is related specifically to ordering, the intent is to reduce the dependency on paper-based ordering processes and improve patient care [3]. However, even if a completely paperless CPOE system or broader EHR system were feasible, current limitations of these clinical applications would make a completely paperless system problematic.

Indeed, the limitations and shortcomings of electronic records were outlined in a recent New England Journal of Medicine commentary [5]. These included copied, repetitive notes that desensitized clinicians to new, important data and more attention directed to the computer, which may result in less attention directed to the patient during patient encounters. These types of scenarios may lead to paper-based workarounds. For example, Hartzband and Groopman presented an anecdote of a colleague who, to manage copied, repetitive electronic notes, used index cards to handwrite new developments so that he could refer to them at the bedside [5]. The underlying issue contributing to the use of paper index cards as a workaround in this example may also be related to the way documentation is performed in the EHR, such as excessive copying from previous notes, rather than simply the apparent convenience of the paper cards themselves.

We investigated use of paper-based workarounds, and the underlying factors that contributed to their existence, at a Veterans Affairs Medical Center (VAMC). This particular VAMC was an ideal site to assess the use of paper with the EHR, as it was undergoing an initiative to eliminate as much paper generation as possible to free space for new interventional radiology equipment in a location currently occupied by a paper file room. Although this VAMC used a widely integrated, nationally used EHR, known as the Computerized Patient Record System (CPRS), a substantial amount of administrative and medical paperwork was processed and stored by the facility. At the time this study began (August 1, 2007), paper accumulated in a designated file room at a rate of approximately eight feet of stacked paper per week. In fact, this was more paper volume than the year prior to the implementation of CPRS at this facility in 1998, where about six feet of stacked paper was received by the file room per week. Larger patient volume and additional paperwork requirements contributed to the larger paper volume today despite the use of an EHR. For example, the U.S. Department of Veterans Affairs (VA) mandates that certain forms be printed and filed, especially if they contain original signatures. System workflow and EHR usability issues also contributed to paper generation. There are also many cases of “temporary” paper (i.e., paper that does not become part of the permanent record); this paper is eventually disposed of in the various sections of the hospital and not sent to the file room for storage.

Previous research has identified several paper-based strategies used by clinicians to circumvent parts of the VA's computerized clinical reminder system [6], suggesting that parts of the CPRS may be inadequately designed to support some clinical workflow and tasks. Recent studies have identified integration of health information technology (IT) into clinical workflow as major challenge for current IT efforts [6], [7], [8], [9], [10], [11]. Further, the way EHRs visually organize patient data may be incompatible with clinical care delivery activities [12]. These situations may cause clinicians to generate paper-based workarounds while using an EHR. Based on this literature, as well as administrative knowledge at our VAMC regarding policy-driven paper processes and systems-level design factors, we developed the framework in Fig. 1 to guide our study.

The framework in Fig. 1 classifies sources of paper generation into three major areas: (1) policy, (2) system design, and (3) EHR design. Predicted sources of paper generation are further depicted at the systems/process level and EHR level. The first category, policy mandate, is a substantial source of paper generation but not related to the scope of the study objective and, thus, was not expanded further. We expanded sub-categories for second category, suboptimal systems design, since they are potentially related to EHR-level factors and informative. The study objective was to explore and understand human-technology integration factors (e.g., computer usability and human–computer interaction issues) at the EHR level that may be causing employees to rely on paper alternatives. Thus, while it was important to understand all sources of paper generation, this study focused on the third category, EHR user interface flaws, and its sub-categories related to human-technology integration factors (d–f). By understanding the motivation behind the use of paper-based alternatives, we expected to find corresponding opportunities to improve EHR design to better support the needs of the clinicians and staff who strive to deliver effective patient care.

Section snippets

Methods

Three of the authors (JS, AR, and CJ) conducted 20 semi-structured, key informant interviews from October 2007 to March 2008 in order to document and understand paper use and paper-based workarounds associated with CPRS and related clinical software. CPRS, as opposed to many EHRs which are more physician-centric, was designed to be used by a broad range of VHA healthcare workers. Thus, we interviewed a convenience sample of employees at the VAMC, including three physicians, two pharmacists, two

Results

From 125 instances of paper use where codes were assigned, we identified 11 categories that represent distinct reasons for paper-based workarounds associated with CPRS. Each category is described in this section and summarized in Table 2; the order of categories corresponds to the occurrence frequency across interview transcripts, beginning with the most frequently identified workaround type. Categories with the same frequency are not listed in a particular order. In several cases, a

Discussion

While EHRs may enhance how data is documented and organized, paper-based processes are not necessarily inefficient or inferior to corresponding computer processes in the EHR. Indeed, for many examples in this study, paper helped some clinicians be more efficient in their work. Campbell et al. notes that “paper often serves as a necessary, sometimes superior, cognitive memory aid” [3]. However, many of these processes circumvent the intended use of the computer system and increase the

Conclusions

We identified 11 categories of paper-based workarounds when using the EHR. In several cases, paper served as an important tool and assisted healthcare employees in their work (e.g., as a cognitive memory and awareness aid). In some cases, paper use also circumvented the intended EHR design. It is possible that information may not be documented in the EHR in a timely fashion or may even be lost. Paper use is beneficial to employees but also a potential source for information gaps and errors.

Acknowledgements

This research was supported by the VA HSR&D Center of Excellence on Implementing Evidence-Based Practice (CIEBP), US Department of Veterans Affairs, pilot grant #LIP 87-012 and HSR&D Center grant #HFP 04-148. A VA HSR&D Associated Health Postdoctoral Fellowship supported Dr. Russ. The views expressed in this article are those of the authors and do not necessarily represent the view of the Department of Veterans Affairs. The authors thank the VA healthcare workers who participated in this study,

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