Electronic Health Record Versus Traditional Paper Records: A Case Study

Electronic Health Record Versus Traditional Paper Records

I spent more than half of my 25 years as a nurse using the traditional paper records. Back then, the computer was only utilized by the unit clerk to order unit supplies. All the patient’s record was stored as hard copies in the chart, from the physician’s order and progress notes to all of nursing documentation. For these reasons, I feel I am in a position to offer a valid personal comparison between paper charting and the Electronic Health Record (EHR).

Paper charting took much of the nurse’s time documenting all and everything that pertained to patient care, from admission assessment, daily nursing care, and medication administration. The thought of automation was likened

to wishing upon a star. It was only in 2012 that the institution took the challenge seriously to embark into computerization. Initially, however, the hospital like most of the other hospitals nationwide, implemented only the minimum recommendations, e.g., laboratory, radiology, pharmacy, and simple nursing documentation (McGonigle & Mastrian, 2015). As I share my insights into the use of the EHR, I still have to experience how it would be when the physicians would comply with the Computerized Physician Order Entry (CPOE) portion of the recommendations.

Advantages of Electronic Health Record (EHR)

In addition to reduction and avoidance of medical errors, cost reduction, and improved quality care (McGonigle & Mastrian, 2015), there had been other documented benefits and advantages of the EHR.

Zhang, Yu, and Shen (2012) cited “three categories of benefits as perceived by the care staff members” (p. 690). All the following gained benefits from EHR, e.g., the care staff members, the patients, and the institutions (Zhang et al., 2012). The most cited benefit from the EHR pertains to the “convenience and efficiency in data entry, distribution, storage, and retrieval of the patient’s record” (Zhang et al., 2012, p. 690). In addition, McGonigle and Mastrian (2015) summarized “the four most common benefits… for the EHR are (1) increased delivery of guidelines-based care, (2) enhanced capacity to perform surveillance and monitoring (3) reduction in medication errors, and (4) decreased use of care” (p. 255). The nurses, in particular, perceived an improvement in the quality of patient care, communication, patient safety, and better care outcomes (McGonigle & Mastrian,

2015).

Disadvantages of Electronic Health Record (EHR)

Without a doubt, the EHR has more edge than paper charting and documentation.

However, to fully benefit from implementing the recommendations as outlined by the American Recovery and Reinvestment Act of 2009 (ARRA), one would need to consider some barriers that could impact the success of computerization in the health care setting. Acceptance by the senior nurses is one hurdle that the organization has to address. The resistance lies more in the lack of computer skills of the seasoned nurses. Thus, this drawback calls for providing adequate training to the nurses that would require more Information Technology (IT) staff, which consequently would impose additional cost to the hospitals. One other concern with the EHR would be maintaining the privacy and security of patient information. McGonigle and Mastrian (2015) aptly cited “Network accessibility and network availability are necessary evils that pose security risks. ... As the cloud expands, so do the concerns over security and privacy. In an ideal world, everyone would understand the potential threats to network security” (p.

226).

Recommendation for Use and Why

Given the points mentioned above, I would still recommend the use of the EHR to pursue and effect the widespread benefits for the patients, the individual caregivers, and the institutions. Just as in any change, people would always find comfort with the old ways of doing things, however, in the final analysis; the overall benefits of the EHR will outweigh the proven disadvantages of paper charting.