Electronic Records

The Electronic Health and Medical Records vs. Paper Records Debate

“We will… wield technology’s wonders to raise health care’s quality and lower its cost.”

— President Barack Obama, Inaugural Address, January 20, 2009

Our world is virtually run by digital technology – smart phones and tablets have transformed our daily lives in the ways we communicate and obtain information. Health care is the maintenance and improvement of our health and bodies; and medical documentation chronicles our individual treatment life and helps health care professionals make treatment decisions. It's hard to ignore the obvious benefits to health care web-based technology as more and more medical practices across the country are transitioning to electronic health care record software systems to help them manage patient data. Electronic health and medical records are able to eliminate errors related to handwriting interpretation in paper-based records and enable round-the-clock access to greater continuity of care. Certainly, medical technology has revolutionized the delivery of health care, but for all the problems it has helped solve, it's also created some new ones.

So, which is better: electronic records or paper?

Terms

Electronic Medical Records (EMRs) are legal, digital versions of the paper charts that are stored in each clinician’s office. An EMR contains the medical and treatment history of the patients in that one practice, tracks which patients are due for screenings or checkups, and monitors overall patient progress and quality of care.

Electronic Health Records (EHRs) are longitudinal electronic records that include all the information found in individual medical records and combines them into one master document that focuses on the total health and medical history of the patient and cumulates all the clinicians involved in the patient’s health care.

Paper Health Records (PHRs) are the health information, lab reports, clinical notes, and health histories of an individual, stored in paper format.

As a part of the United States’ American Recovery and Reinvestment Act of 2009, all public and private health care providers are required to adopt “meaningful use” of certified EMR/EHR technology in order to maintain their existing Medicaid and Medicare reimbursement levels.

Many people in the health care industry, government, and media use the electronic medical records and electronic health records interchangeably; even though they are completely different concepts, as seen above. However, for the purposes of the remainder of this article they too will be used interchangeably.

Cost Effectiveness

Although health care providers will experience some initial costs during the implementation of the electronic record storing system, the cost of maintaining the records over time will decrease. Paper-based records require personnel and physical storage space in order to manage and maintain files. An electronic filing and storage system will reduce the need for these transcription services.

Despite the cost of implementation, federal and state governments are heavily promoting the employment of electronic medical and health records nationwide. As part of the Health Information Technology for Economic and Clinical Health Act enacted as part of the previously mentioned American Recovery and Reinvestment Act, Congress introduced a formula of incentives (up to $44,000 per physician under Medicare, or up to $65,000 over six years under Medicaid) and penalties (decreased Medicare and Medicaid reimbursements to clinicians who fail to adopt the electronic system) for EMR/EHR adoption versus continued use of paper records.

Legal Status

While there is no argument that constantly updated electronic documentation of a patient’s health status brings improved care, there is increasing concern among legal experts and medical personnel that such documentation could open physicians to an increased incidence of malpractice suits. With the option of selecting from dropdown menus and the use of templates, technological features can easily encourage physicians to skip sections and not conduct a complete review of past patient history and medications, thus missing important data.

Many physicians are unaware that electronic record systems produce an electronic time stamp every time a patient record is updated. With the use of templates and dropdown menus, not only will these features encourage physicians to skip a complete review of patient medical history, but will also encourage personnel to wait until the end of the day to chart patient notes or make addendums to records well after the patient’s visit. Such changes can be problematic, in that this practice could result in less than accurate patient data or indicating possible intent to illegally alter the patient's records, whether or not this was the physician’s motive for delayed documentation. Legal experts argue that if a malpractice claim is brought to court, the prosecution can request through the process of discovery, a detailed reports of all entries made in a patient's electronic record. This would include the electronic timestamps as well as argue that the clinician failed to review all relevant patient information to which they have reasonable access resulting in a possible missed or misdiagnosis.

Security

Paper records can be both a help and a limitation to security. Some argue that keys to storage areas can be stolen and documents illegally replicated, and that paper records are at greater risk of being misplaced or lost. Others argue that paper medical records are easy to lock away safely, while electronic systems are vulnerable to hackers. These same people also argue that paper records are easier to contain and because of the limited number of people who have access to the patient information, it is less likely for such information to make it into the hands of those who shouldn’t see them.

However, records that are exchanged and stored over the internet are subject to the same security concerns as any other type of data transaction. Currently, there are several federal investigation reports which conclude that there is no clear strategy to protect the privacy of patient information within the increased portability and accessibility of electronic health and medical records.

The Health Insurance Portability and Accountability Act (HIPAA) has developed a strategy to mitigate the threat of hackers, but policies that do not limit the options of health care professionals who may have access to different technology. By regulation, the Department of Health and Human Services has extended the HIPAA privacy rule to over an individual’s health status, provision of health care, or payment for health care.

Accuracy

Advocates for the continued adoption of the EHR/EMR system argue that paper medical and health records are often difficult to understand due to illegible writing and important information can be lost or misinterpreted based on the writer and reader of the recorded information. Paper records also have limited space on each page, making it difficult for health care providers to include all relevant information available in the document. In contrast, electronic records are easy to read and provide plenty of space for detailed record keeping, decreasing human error due to handwriting issues and limited storage space, both physically and on the page.

Handwriting is automatic, but for some, using a computer is not. Handwriting allows for more thought and focus on patient data; studies show that handwriting information significantly increases a person’s chance of remembering relevant information, hence helping a physician to more quickly diagnose and manage a patient’s illness. However, the recent development of digital pens that record and transcribe handwriting might reduce the cognitive load associated with typing information into electronic records, providing an automated link to electronic aids within the recording system the clinic has installed.

As also pointed out in the legal section above, the use computer filing will encourage physicians and medical personnel to wait until the end of the day to chart patient notes well after the patient visit, instead of physically writing down the information as it is received.

Patient Safety

Improved patient safety is the most important benefit of EMR/EHR adoption. The improved legibility of typed clinical records not only decreases the chance of the misinterpretation of information, but electronic recording systems also allow the option of issuing important reminders about tests or other medical services that are due. Studies show that by allowing physicians access to an electronic summary list of past diagnoses, surgeries, and patient allergies, such management modules actually lowered mortality rates among patients.

Advocates for the continuation of paper-based systems of record keeping argue that EHR/EMR models are often confused with personal health record models, which leads to widespread assumptions that individual patients will aggregate each of their own records and make them selectively available to health care providers of their choosing. By continuing the practice of handwritten, paper records, the odds of a patient’s information getting lost or separated decreases, while increasing the accessibility of the information to emergency providers in a crisis.

Accessibility

In contrast with the argument above regarding the accessibility of medical information in paper-records during an emergency, such paper records are not always readily available to patients or health care providers on a regular basis. It is common for record requests to be processed and then sent to a provider from a warehouse or storage facility. Not only is this process tedious and expensive, but it leaves significant room for human error as well, through mailing and processing fees as well as the possibility of the wrong records being sent. The use of electronic health and medical records allow health care professionals to access patient information immediately and improve treatment time and transmittance of records to patients and other health care providers.

Business concerns and structural changes in the health care system are also driving EHR/EMR implementation. The shift from inpatient to outpatient care has accelerated the need for accurate and efficient flow of patient information between providers. However, older medical personnel aren’t as tech-savvy with computers as their younger counterparts. Paper records are easy for everyone in a health care facility to use and require minimal skill, while electronic recording systems require a fair amount of user knowledge and skill.

Hospitals and other medical facilities also use and store paper-based records of a patient's chart in a special holder attached to their hospital bed. This system makes it easy for physicians, nurses, social workers, and other health care staff to quickly find patient information. During a medical emergency, medical personnel don't have time to access a computer terminal or scroll through multiple screens to see the patient's history. When time is of the essence, physical paper records move the process of information gathering much quicker.

Changes in technology and information trading are a healthy sign of the evolution of communication. The implementation of electronic health and medical recording systems are indications that medical practices are naturally evolving and willing to adapt to a universal integration system of patient health information exchange between various providers. As EHR/EMR systems mature and develop, many health care facilities are still sitting on the sidelines, either unaware of or apathetic towards the advantages and the continuous advancement of technology.

In reality, there needs to be a steady medium between the use of digital record keeping and the “old-school” paper records. Rather than the pro-technology side constantly explaining and re-explaining how things are supposed to work, they should try to just listen to medical practitioners and really attempt to understand what their daily life in a clinic is like. Likewise, practitioners who rely on paper-based records should take time to analyze their current processes and see how they can improve instead of complaining that the new, alternative system doesn’t work to fit their processes.

There are obvious benefits of having data available electronically, however, most providers and clinics have yet to completely integrate a fully functional EHR. Most providers and clinics still have largely paper-based record systems. A paperless environment is not necessarily a desirable end goal and having the option to use either paper, electronic, or a combination of the two record keeping systems is important.


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