The DOI matches its Crossref record; 28 of the 28 references it cites were found in a registry or an index.
Exploring the persistence of paper with the electronic health record
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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“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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Cites
Kawamoto, K., Houlihan, C. A., Balas, E. A., & Lobach, D. F. (2005) · BMJ · doi:10.1136/bmj.38398.500764.8f · Cited by 2,703
Bates, D. W., Kuperman, G. J., Wang, S., Gandhi, T., Kittler, A., Volk, L., Spurr, C., Khorasani, R., Tanasijevic, M., & Middleton, B. (2003) · Journal of the American Medical Informatics Association · doi:10.1197/jamia.m1370 · Cited by 1,346
Types of Unintended Consequences Related to Computerized Provider Order Entry
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Kuperman, G. J., Bobb, A., Payne, T. H., Avery, A. J., Gandhi, T. K., Burns, G., Classen, D. C., & Bates, D. W. (2007) · Journal of the American Medical Informatics Association · doi:10.1197/jamia.m2170 · Cited by 763
The Extent and Importance of Unintended Consequences Related to Computerized Provider Order Entry
Ash, J. S., Sittig, D. F., Poon, E. G., Guappone, K. P., Campbell, E., & Dykstra, R. H. (2007) · Journal of the American Medical Informatics Association · doi:10.1197/jamia.m2373 · Cited by 511
Patterson, E. S., Cook, R. I., & Render, M. L. (2002) · Journal of the American Medical Informatics Association · doi:10.1197/jamia.m1061 · Cited by 370
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Metadata
- 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
- Semantic Scholar
- 6f73746d8f0c94b5309f7465ff317ebb22d05f29
- 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 › Research and Theory › Nursing Diagnosis and Documentation
- Social Sciences › Business, Management and Accounting › Management Information Systems › 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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