Life with and without electronic health records

Paper-based records are still the preferred method of recording, storing, and retrieving patient information in many hospitals and doctors' offices. They are simple, easy, and very cost effective. But there are drawbacks and limitations in using paper records, including limited access (you must physically have the chart), risk of misplacing the charts, difficulty in transporting multiple charts on rounds, time consumed finding specific data in charts; extensive storage space, and difficulty in finding past information (such as the patient's hospitalization 2 years ago). It is also more difficult to get into old x-rays, CT scans, and cardiograms. Handwritten paper medical records also can be associated with poor legibility, which can contribute to medical errors. In 1999, an Institute of Medicine report estimated that as many as 98,000 medical error-related deaths occur each year in the United States ("To Err is Human: Building a Safer Health System"). A significant share of those errors is caused by poor medical recording or errors in retrieving what is written by healthcare personnel, including doctors, pharmacists, nurses, and laboratory staff.

I had the privilege of working with EHRs about 10 years ago when I was in a multispecialty group practice with about 35 physicians. After 5 years of becoming accustomed to EHRs, I left the group and joined another practice, where I had to switch back to paper-based medical records. Thus, I experienced my professional life with EHRs and then without EHRs.

When we decided which EHR brand we were going to use, the company's representatives gave us extensive training on the system. It was time-consuming and stressful. Our nursing and other ancillary staff also needed to be trained.

The first few months of using the system were chaotic. There was utter confusion all over the clinic: in the doctors' offices, the hallways, medical record departments, labs, and radiology. A few nurses even quit because they said they could not handle the stress. All the past paper records were scanned into the electronic system, and the physicians were asked to identify the areas of the medical records that needed to be carried into the new system.

The electronic documenting capability enabled us to record patient demographics, chief complaint, physical examination, labs, diagnosis, and contemplated treatments. We were able to send prescriptions directly to the pharmacy of the patient's choice and set up return appointments. We could use electronic forms (templates) specific to the type of visit (first time or follow-up) or specific to the patient's disease or condition (for instance, diabetes or back pain).

The electronic templates prompted us to guide the clinical exam and discuss preventive care-such as exercise regimens, fluid intake, special diet-with patients. Some of those instructions could be printed and given to patients. We also could provide patients with detailed, disease-specific educational brochures. And all of this could be accomplished with a simple mouse click.