Paper-Based Workarounds and Electronic Health Records (EHR)

July 22, 2009 by · Leave a Comment
Filed under: health care 

The September 2009 issue of the International Journal of Medical Informatics includes an article entitled “Exploring the Persistence of Paper with the Electronic Health Record.”

According to the authors, “the study objective was to explore and understand human-technology integration factors (e.g., computer usability and human–computer interaction issues) at the EHR level that may be causing employees to rely on paper alternatives” (p. 619).  The authors conducted interviews of twenty employees (physicians, pharmacists, nurse practitioners, registered nurses, health technicians, dietician, administrators, and IT specialists) who use a Computerized Patient Record System (CPRS), a type of electronic health record (EHR), at a Veterans Affairs Medical Center.  The questions focused on three sub-categories, including:

  • Cumbersome EHR interface design;
  • EHR not well integrated into clinical flow; and
  • Visual organization of data in EHR incompatible with clinicians’ mental model.

The responses were divided into 11 categories of reasons why paper-based workarounds were used (p. 621), in descending order of frequency, including:

  • Efficiency;
  • Knowledge/skill/ease of use;
  • Memory;
  • Sensorimotor preferences;
  • Awareness;
  • Task specificity;
  • Task complexity;
  • Data organization;
  • Longitudinal data processes;
  • Trust; and
  • Security.

Besides providing explanations and examples supporting each of the 11 categories, the authors also raise several important points, including:

  • “…workaround strategies may increase efficiency but create new potential paths to medical error. Therefore, a well-designed EHR should support the use of important paper supplementation while minimizing the potential for gaps in EHR documentation” (p. 624)
  • “The efficiency finding for paper persistence has two distinct implications. One is that the paper workaround phenomena indicated the EHR was not sufficiently designed and does not efficiently support clinicians’ work and/or is not aligned with clinicians’ natural workflow. Secondly, some paper workarounds replaced important EHR documentation or circumvented critical EHR-designed safety checks. These workarounds may lead to potential gaps in documentation and potential patient safety risks.” (p. 624)
  • “Poor ease of use, or usability, of CPRS and related heath IT also led to the use of paper. For example, in the acute dialysis unit, usability issues hindered a new computer process intended to automate patient vitals entry into CPRS, and has delayed future roll-out to the rest of the dialysis service.” (p. 625)
  • “…advances in technology such as light weight notebook computers and highly usable personal digital assistants (PDAs) still do not necessarily afford the same level of convenience or integration into clinical workflow as paper and pen.” (p. 625)
  • “Paper workarounds were employed when CPRS did not support the specificity or complexity of the clinical task.” (p. 625).
  • “…some persistent paper use may also simply be due to a reluctance to change.” (p. 627)


Salem, J.J., Russ, A.L., Justice, C.F., Hagg, H., Ebright, P.R., Woodbridge, P.A., & Doebbeling, B.N. (2009).  Exploring the persistence of paper with the electronic health record.  International Journal of Medical Informatics, 79, 618-628.

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