Effects of Scanning and Eliminating Paper-Based Medical Records on Hospital Physicians’ Clinical Work Practice

Design: Combined open-ended interviews (8 physicians) and cross-sectional survey (70 physicians) were conducted and compared with reference data from a previous national survey (69 physicians from six hospitals). The hospitals in the reference group were using the same EMR system without the scanning module. Measurements: The questionnaire (English translation available as an online data supplement at www.jamia.org) covered frequency of use of the EMR system for 19 defined tasks, ease of performing them, and user satisfaction. The interviews were open-ended. Results: The physicians routinely used the system for nine of 11 tasks regarding retrieval of patient data, which the majority of the physicians found more easily performed than before. However, 22% to 25% of the physicians found retrieval of patient data more difficult, particularly among internists (33%). Overall, the physicians were equally satisfied with the part of the system handling the regular electronic data as that of the physicians in the reference group. They were, however, much less satisfied with the use of scanned document images than that of regular electronic data, using the former less frequently than the latter. Conclusions: Scanning and elimination of the paper-based medical record is feasible, but the scanned document images should be considered an intermediate stage toward fully electronic medical records. To our knowledge, this is the first assessment from a hospital in the process of completing such a scanning project. j J Am Med Inform Assoc. 2003;10:1–8. DOI 10.1197/jamia.M1337. The electronic medical record (EMR) is considered a prerequisite for the efficient storage, distribution, and use of patient data in hospitals. The development and implementation of EMR systems that have the capability of storing and presenting all the information contained in a typical paper-based medical record have, however, proven to be complex tasks. In Norway, systems with the ability of storing a proportion of the information in the paper-based medical record are implemented in most hospitals. Until recently, Norwegian legislation has made it necessary to maintain the paper-based medical records, resulting in a combined electronic and paper-based medical record best described as a hybrid (Fig. 1). In this situation, the EMR systems are of limited value to physicians. A revised legislation, enacted in January 2001, defines criteria for how the patient data can be stored solely in an electronic format. However, to obtain a complete record, several paperbased sources of patient data must be converted to a digital format without loss of medical or legal information. This includes the paper-based medical record as well as paper documents that have been created by hand or that stem from diagnostic devices or information systems not integrated with the EMR system. In practice, it means that a complete EMR system must support scanning and storage of documents as images. Having two complete copies of a medical record is superfluous, and the next logical step is an elimination of the paperbased medical record. Since no alternative system will be available to the physician in case of failure of the computer system, this can be considered a strategy of no return. Such a radical change in work methods carries a risk of full refusal by the clinical staff, as has been reported in previous studies. These aspects probably discourage hospitals from taking this next step toward computerization. Although scanning of paper-based medical records in hospitals has been described by others, the effects of eliminating them are not known. In Affiliations of the authors: INM, Faculty of Medicine, NTNU, Trondheim, Norway (HL, AF); Sørlandet Sykehus HF Arendal, Norway (formerly called Aust-Agder Sykehus HF) (THK). The authors thank Gerd Gulstad, Bjørn Engum, Tom Schulz, AnneBrit Riiser, and Astrid Norberg for their continued help and support. This investigation is funded by the Norwegian Ministry of Health and the Research Council of Norway through the Kvalis project at the Norwegian University of Science and Technology, Trondheim. Correspondence and reprints: Hallvard Lærum, DigiMed Centre, Elgesetergate 10, N-7465 Trondheim, Norway; e-mail: . Received for publication: 01/28/03; accepted for publication: 07/16/03. 1 Journal of the American Medical Informatics Association Volume 10 Number 6 Nov / Dec 2003 JAMIA73_proof 26 AUGUST 2003 ARTICLE IN PRESS