President Bush responded to the Institute Of Medicine’s charge that healthcare in the US was too costly, inefficient, and questionably effective. In his 2004 State of the Union address, and during the presidential campaign, President Bush called for the nation to eliminate paper medical records within a decade. Most in the industry yawned. The electronic medical record still isn’t saving enough trees and, we will have made it to the moon in less time.
Clinical practice is steeped in the tradition of paper to record, communicate and reference patient information. Habits are hard to break, especially if it requires learning something new, and exposing skill limitations along the way all at an enormous expense. Holding on to a piece of paper in plain sight is much more reassuring than the virtual reality hiding behind a display screen. Electronic records are a threat to the way we practice and value patient care.
“Meaningful use” is the motivation and driving force behind electronic health records with the goal of creating a digital care environment that improves clinical processes and care delivery. Data entered electronically and then accessed online results in information that is up-to-date, relevant and available anywhere, anytime. With paper records, information is restricted to one at a time access and limited by the physical location of the record; clinicians make decisions without timely or complete information. The electronic record puts this information at the bedside or in the therapy gym when it is needed.
Clinical decision-making, patient safety and the operational benefits associated with digital records should be sufficient motivation to move away from a paper environment. However, the reluctance to let go of our paper habit has slowed the transformation to a crawl. Each step taken by a hospital to adopt electronic vs. paper practices is made agonizingly painful by cautious scrutiny and “test as we go” implementations. Thought leaders insist upon maintaining the paper record as a backup or safety net in case something gets missed. The phase in approach may seem like a prudent strategy to enter digital practice with a paper backup always ready. The cost and frustration of operating dual systems is evident to all who take this approach only to push out further the clinical and financial benefits of meaningful use. Holding on to paper when electronic data is available may be comforting to those just learning to walk in this electronic environment, but at some point it becomes the limiting factor in getting to where you need to go. Printing information that exists electronically and archiving it in a binder is a symptom of unnecessary cost and effort only to support old habit conveniences.
Rehab exists on the back end of most healthcare episodes and does not always receive the technological and resource benefits of acute care venues. The transformation to electronic records and digital practice for the rehab program will most likely happen only after it occurs upstream in the continuum. The risk here is the digital record systems and practices eventually handed down from the acute venue to rehab are often the equivalent of an older sibling’s second hand running shoes. The fit and ultimate performance lacks the specific application to your individual purpose. This realization should not occur after a lengthy transition process prolonged by implementation with uncertainty practices and paper based backups. Clinical transformation will be accelerated and the resulting operational and clinical efficiencies become readily apparent if only one rehab specific system exists and whenever digital information is available its shadow is expired from the paper record.
The digital rehab requirement will not likely be met with second hand solutions. Learning to do something digitally while maintaining alternative requirements to do the same task in another system is wasteful and if prolonged will generate revolt among clinicians.
A plan to achieve meaningful use by converting existing paper based habits, documents and forms often falls short of meeting the expectations for practice improvement and quality initiatives. With comprehensive digital strategies and policies in place, organizations transition to electronic processes all at once rather than converting paper processes one-by-one and replacing each with an electronic process. The fear and pain of change is minimized when leaders mandate to solve operational problems without paper. Old habits die hard and paper has always been the easy answer.
Clinical information readily available at the point of care helps improve care. When electronic systems provide clinical alerts and easy access to best practice information clinical activities and decision-making optimize the value of patient care. With the continuing challenges of cost and effectiveness of rehabilitation facing all providers, one must ask, how long can we support old habits as the plan to succeed in the future?