Paperless Medical Enterprises?

Many general practices are developing into paperless enterprises, which have a fully integrated Windows-based system including access to full electronic medical records.¹ Improvements in information flow technologies, supportive national and local policies, as well as a motivated practice and a local champion with good management skills have contributed to the successful integration of computers. These improvements have subsequently moved many general practices forward towards becoming paperless. Hospitals have generally lagged behind general practices in making such improvements to their IT infrastructures.² It is generally the limited and uncoordinated development of Information Technology (IT) within the hospital or the general practice that prevents or discourages doctors from migrating towards becoming completely paperless.³ The development of paperless medical records which link with a multitude of other NHS activity and IT is part of national policy.⁴ A lot of money has been spent to achieve progress with these plans. The move towards paperless medical practice seems inevitable, massive and momentous.

There has been a relentless move with computerisation of practices towards paperless clinical records and paperless practice activity generally. The NHS information strategy, the national service frameworks, and the NHS plan all promote the use of electronic patient records.⁵ The national specification for integrated care records service aims to develop clinical records, which are to be designed around the patient, integrated across all health and social care settings, and capable of supporting the implementation of care pathways within the national service frameworks.⁵ Good quality electronic records, generally, can be used to prompt:

• Improvements in patient care
• Better coordination of care between primary and secondary care⁶
• Improvements in the monitoring of the health of populations
• Improvements in primary care based research

Electronic records are now routinely used to demonstrate that practices have achieved the national quality standards, and remuneration or allowances are linked to the achievement of national targets. Apart from the national initiatives and the broad and general benefits perceived, there will also be important local and practice issues to be considered.

Advantages and disadvantages of becoming a paperless practice

Computerisation has traditionally been seen as enabling improvements in the quality of care given by a practice. A variety of advantages and disadvantages have been cited.¹
Advantages

• To overcome problems and delay when transferring paper medical records⁷
• To improve problems with loss or misplacement of physical paper records and record envelopes
• To save time spent on handling paper records
• Information can be shared more easily⁸
• Email and intranet communication within the practice reduces internal paper flows, telephone calls and faxes
• Increases security and confidentiality because it is easier to control and audit access to records
• Convenience
• Complies with the national initiatives
• Local peer pressure
• Opportunity to improve the existing electronic patient records (EPR)
• Improves data quality
• More efficient and effective consultations (all information is available and up-to-date)
• Universal legibility of data entries
• Mixing of paper and electronic records causes confusion
• Ease of collecting/retrieving specific information (for example audit data, product safety recalls, prompts for patient management and data entry)
• Patient access to records can be an advantage (more transparency, equality within the doctor-patient relationship)

• Data security^9,10
• Document managing and scanning have proved problematic¹
• Staff training (time, costs, standards)
• Lack of IT standards for GP staff
• Problems with data backup (if data is lost or if system goes down)
• Lack of national protocol
• Problems with sharing information externally between practices (easier to carry an envelope)
• Fear of change and unknown
• Lack of internal protocols within practice
• Health and safety issues regarding more time spent at VDU.
• Less effective consultations as dominated by technology (but patients do not seem to complain)
• It takes more time for clinicians to read documents such as clinical letters on screen
• Patients may use Data Protection Act to view notes which can have significant workload implications¹¹

• Motivate the practice staff through developing an understanding of the benefits of the proposed change
• Commitment to retraining staff
• A comprehensive retraining package

There are many different document-related activities that can be analysed for investigating the practical implications of migrating towards a paperless medical organisation. For example, analysis of the preoperative risk assessment (PRA) form can illustrate how the practical use of documents by medical practitioners can often be fundamentally at odds with organisational aims and purposes.² Data entry into electronic format by anaesthetists using the PRA form is tedious and an additional activity that is required purely for reasons outside the local concerns of the medical professional.²

Pros:

• Reduced costs of storage space
• Aggregation of data with online access
• Every field must be filled leading to completeness of records by preventing the bypassing of fields until all data are entered e.g. PRA form
• Link to a centralised data store thereby reducing redundant form filling
• Easier access and retrieval compared to paper notes, and those generated by different departments or hospitals
• Data is up-to-date
• Remote access to information, which could allow consultants to access information when and where they need it, as well as release trainees from telephoning their superiors for information

• Paper is flexible, markable, portable and accessible i.e. PRA forms
• Electronic systems are more structured with constrained interfaces
• Input via keyboards
• Immobile and cumbersome to navigate
• Problems of screen size, viewing angle and the ability to share multiple documents concurrently by people in the same room

However, poor system design and poor investment means that hospital doctors do not use computers.³ Elements that need to be addressed before hospitals migrate more towards becoming paperless organisations include:

• Computers readily available to all doctors
• Sensible security measures in place
• Email with remote access
• All patient details (including past letters etc.) accessible
• Pathology results and medical records readily accessible
• Good access to the Internet so reading of e.g. medical journals was convenient

Electronic Patient Records (EPRs) are the recommended format promoted by the NHS information strategy, the National Service Frameworks, and the NHS plan.⁵ EPRs aim to improve patient care, improve the communication and coordination of care between primary and secondary health care services, monitor the health of populations, and undertake primary care research.⁵ Concerns regarding reliability of software have improved greatly. There are still issues around the confidentiality and legality of EPRs. Additionally, there is no supportive evidence to show that doctors would enter less information and detail than they would using paper records, or that doctors would remember less about each consultation due to the use of technology during the consultation.⁵ EPRs are legible and more accessible, plus EPRs have the added advantage of a coded structure, enabling the automated restructuring of records, queries on data such as disease registers, decision support systems, speed, guidance, validation of data input, and electronic messaging (e.g. for laboratory results).¹²