Paper Use with the Electronic Medical Record: An Important Supplement or Negative Circumvention?

Abstract

Healthcare organizations are increasingly implementing electronic medical records (EMRs) and other related health information technology (IT). Even in institutions which have long adopted these computerized systems, there are still instances where employees rely on paper to complete their work. The use of paper suggests that parts of the EMR may not be sufficiently designed to support clinicians and their work processes. To understand the use of paper-based alternatives, we conducted 14 key-informant interviews in a large Veterans Affairs Medical Center (VAMC), with a fully implemented EMR. We found nine distinct categories of paper-based workarounds to the use of the EMR. In several cases, paper served as an important tool and assisted healthcare employees in their work. In other cases, paper use circumvented the intended EMR design, introduced potential gaps in documentation, and generated possible paths to medical error. We discuss implications of these findings for EMR design and implementation.

Get full access to this article

View all access options for this article.

References

Bates

D. W.

Kuperman

G. J.

Wang

Gandhi

Kittler

Volk

et al. (2003). Ten commandments for effective clinical decision support: Making the practice of evidence-based medicine a reality. J. Am. Med. Inform. Assoc., 10, 523–530.

Campbell

E. M.

Sittig

D. F.

Ash

J. S.

Guappone

K. P.

Dykstra

R. H.

(2006). Types of unintended consequences related to computerized provider order entry. J. Am. Med. Inform. Assoc., 13, 547–556.

Doebbeling

B. N.

Chou

A. F.

Tierney

W. M.

(2006). Priorities and strategies for the implementation of integrated informatics and communications technology to improve evidence-based practice. J. Gen. Intern. Med., 21 Suppl 2, S50–S57.

Kawamoto

Houlihan

C. A.

Balas

E. A.

Lobach

D. F.

(2005). Improving clinical practice using clinical decision support systems: A systematic review of trials to identify features critical to success. BMJ, 330, 765.

Kuperman

G. J.

Bobb

Payne

T. H.

Avery

A. J.

Gandhi

T. K.

Burns

et al. (2007). Medication-related clinical decision support in computerized provider order entry systems: A review. J. Am. Med. Inform. Assoc., 14, 29–40.

Linder

J. A.

Bates

D. W.

Middleton

Stafford

R. S.

(2007). Electronic health record use and the quality of ambulatory care in the United States. Arch. Intern. Med., 167, 1400–1405.

Militello

Patterson

E. S.

Tripp-Reimer

Asch

S. M.

Fung

C. H.

Glassman

et al. (2004). Clinical Reminders: Why Don't They Use Them? Proc Human Factors and Ergonomics Society's 48th Annual Meeting, 1651–1655.

Patterson

E. S.

Cook

R. I.

Render

M. L.

(2002). Improving patient safety by identifying side effects from introducing bar coding in medication administration. J. Am. Med. Inform. Assoc., 9, 540–553.

Patterson

E. S.

Nguyen

A. D.

Halloran

J. P.

Asch

S. M.

(2004). Human factors barriers to the effective use of ten HIV clinical reminders. J. Am. Med. Inform. Assoc., 11, 50–59.

10.

Patterson

E. S.

Rogers

M. L.

Chapman

R. J.

Render

M. L.

(2006). Compliance with intended use of Bar Code Medication Administration in acute and long-term care: An observational study. Hum. Factors, 48, 15–22.

11.

Powsner

S. M.

Wyatt

J. C.

Wright

(1998). Opportunities for and challenges of computerisation. Lancet, 352, 1617–1622.

12.

Saleem

J. J.

Patterson

E. S.

Militello

Render

M. L.

Orshansky

Asch

S. M.

(2005). Exploring barriers and facilitators to the use of computerized clinical reminders. J. Am. Med. Inform. Assoc., 12, 438–447.

13.

Varpio

Schryer

C. F.

Lehoux

Lingard

(2006). Working off the record: Physicians' and nurses' transformations of electronic patient record-based patient information. Acad. Med., 81, S35–S39.

14.

Xiao

Vicente

K. J.

(2000). A framework for epistemological analysis in empirical (laboratory and field) studies. Hum. Factors, 42, 87–101.