Cited by 146Electronic Health Records SystemsNursing Diagnosis and DocumentationInformation Systems Theories and Implementation

Exploring the persistence of paper with the electronic health record

Saleem, Jason J., Russ, Alissa L., Justice, Connie F., Hagg, Heather, Ebright, Patricia R., Woodbridge, Peter A., Doebbeling, Bradley N.·2009·International Journal of Medical Informatics

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.

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Crossref · 10.1016/j.ijmedinf.2009.04.001

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  • Paper continues to be used extensively at a large Veterans Affairs Medical Center where EHRs have existed for 10 years.

    “The paper persistence problem was recently explored at a large Veterans Affairs Medical Center 84 where EHRs have existed for 10 years. Paper continues to be used extensively.”

    From Health information technology: fallacies and sober realities (2010) · cites this paper as [84]

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Authors
Saleem, J. J., Russ, A. L., Justice, C. F., Hagg, H., Ebright, P. R., Woodbridge, P. A., & Doebbeling, B. N.
Affiliations
  • Regenstrief Institute (US)
  • Indiana University Indianapolis (US)
  • VA Nebraska Western Iowa Health Care System (US)
Corresponding author
Saleem, Jason J.
Venue
International Journal of Medical Informatics
Publisher
Elsevier BV
Published
2009-09
Volume
78
Issue
9
Pages
618-628
ISSN
1386-5056 (ISSN-L)
OpenAlex
W1965739756
Cited by
145
References
28
Citations by year
2026: 3 · 2025: 3 · 2024: 3 · 2023: 2 · 2022: 8 · 2021: 6 · 2020: 6 · 2019: 7 · 2018: 10 · 2017: 6 · 2016: 12 · 2015: 11 · 2014: 12 · 2013: 15 · 2012: 9
FWCI
29.55
Type
journal article
Language
en
Open access
closed
Locations
  • International Journal of Medical Informatics (publishedVersion)
  • PubMed (publishedVersion)
Funders
Health Services Research and Development
Topics
  • Health Sciences › Health Professions › Health Information Management › Electronic Health Records Systems
  • Health Sciences › Nursing › Issues, ethics and legal aspects › Nursing Diagnosis and Documentation
  • Social Sciences › Sociology and Political Science › Information Systems Theories and Implementation
Keywords
electronic health records, human-technology integration, health information technology adoption, EHR design, clinical documentation, medical errors, veterans' health care, clinician behavior, task complexity, data security
MeSH terms
Documentation, Indiana, Medical History Taking, Paper, Practice Patterns, Physicians', Medical Records Systems, Computerized

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