Exploring the persistence of paper with the electronic health record.
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.
Saleem
Jason J
JJ
VA HSR&D Center on Implementing Evidence-Based Practice, Roudebush VAMC, Indianapolis, IN 46202, USA. Jason.Saleem@va.gov
Russ
Alissa L
AL
Justice
Connie F
CF
Hagg
Heather
H
Ebright
Patricia R
PR
Woodbridge
Peter A
PA
Doebbeling
Bradley N
BN
D004282:Documentation / Q000706:statistics & numerical data*; D007196:Indiana; D008487:Medical History Taking / Q000379:methods* / Q000706:statistics & numerical data*; D016347:Medical Records Systems, Computerized / Q000706:statistics & numerical data*; D010209:Paper; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*