Review: Why Is There Paper In The Paperless System?


The article reviewed here is ‘Exploring the Persistence of Paper with the Electronic Health Record’ by Saleem and colleagues. The advent of the computer brought with it the promise of a revolution in the way that we work and visions of endless tasks that could be automated and data that could be stored out of sight and called up at any time from multiple locations. Much of that vision has been realised but paper based systems still persist even when electronic alternatives are available. This applies to health services as well as other sectors. The researchers in this study wanted to find out why health care workers continued to use paper based systems when electronic alternatives were available. They used a qualitative approach and in the paper’s abstract they conclude that 

In several cases, paper served as an important tool and assisted healthcare employees in their work. In other cases, paper use circumvented the intended EHR design, introduced potential gaps in documentation, and generated possible paths to medical error

The authors have therefore found both advantages and disadvantages to the use of paper from their study although their conclusions include the qualifiers ‘potential’ and ‘possible’. Furthermore, these results represent the healthcare worker’s opinions and experience of working within the system and therefore tell us about the system itself indirectly. Ideally this information could have been used to generate simple hypotheses which could have been tested using data from the system itself. Even so, it’s interesting to hear from the people using the system as their views may be translatable to similar services elsewhere.

What was the methodology?

The researchers conducted 20 semi-structured interviews with ‘key informants’ consisting of multidisciplinary professionals including doctors, nurses, pharmacists, IT and administrative staff. They provided an interview script in the Appendix. The term CPRS given in the example questions refers to the computerised records system. The questions were grouped into those for clinical staff and those for IT personnel. An example of a question for the clinical staff is 

What is your ideal workflow during your clinical work and how does it relate to CPRS?

An example of a question for the IT and administrative staff is 

Are there workflow improvements that you envision that could eliminate or reduce production and storage of some paper forms? Please explain

The questions were exploratory. This meant that the researcher could respond with further unscripted questioning depending on the subjects answers. 

What were the results?

The results were grouped into themes. They were difficult to summarise given the heterogenous responses elicited but some of my highlights are given below

1. Efficiency. Doctors would prefer to handwrite complex orders as this was thought more difficult using the system.

2. ‘Knowledge/skill/ease of use’. In some cases clinicians were simply uncomfortable using the system and in other cases were unaware that tasks could be completed within the system.

3. Memory. This was interesting. Some clinicians used paper to help them remember things.

4. Sensorimotor preferences. Subjects would sometimes like to hold the paper as it was ‘tangible’ and a physician expressed the view that it would impair communication with the patient if used during the interview (although from the comment, I think this rests on the assumption that the clinician would have to face away from the patient while using the computer).







5. Awareness. In some cases, staff would ask the patient to hand their blood pressure measurements in paper form to the physician

6. Task specificity. Sometimes the system would present the physician with information relevant instead to their colleagues. One physician therefore ensured that only alerts relevant to him/her were printed out and stored.

7. Task complexity. At times the system could not manage certain complex tasks at all and a paper workaround was necessary.

8. Data organisation. Clinicians sometimes needed to view the data in different formats that were unsupported and moved instead to paper.

9. ‘Longitudinal data processes’. The researchers cite the example of viewing longitudinal INR values which was not possible on the computer system.

10. Trust. Paper was viewed by one clinician (secondary source) as providing ‘proof’ that they had documented an item.

11. Security. Due to use of a university e-mail account, paper print-outs were used in one case to avoid use of the e-mail.


The authors discuss the results above and draw a number of conclusions including the following:-

Paper-based processes are not always inefficient or inferior to corresponding computer processes. However, paper processes may circumvent the intended use of the computer system, increase the opportunity for losing clinical information, and create new potnetial paths to medical error

However, there are a number of limitations to this study. Firstly, the researchers did not conduct further tests to verify the results objectively. For instance, they could have observed subjects engaged in tasks and quantified their work patterns as further supporting evidence. Thus these results serve to inform further studies. Secondly, there is a small sample set consisting of professionals from a number of different disciplines. Doctors form a small sample of this group. Thus to gain more useful information specific to a profession such as doctors, further studies would be required. Thirdly, the study relates to a very specific computer system at a specific point in time and therefore a number of the results may become redundant as the system is further refined through time. 

In conclusion, the study provides preliminary evidence that paper has many useful properties which have not been translated into one example of a computerised patient record system. Perhaps this is unsurprising, given the amount of time which paper has been used in civilisation.



Saleem J J et al. Exploring the Persistence of Paper with the Electronic Health Record. International Journal of Medical Informatics. 78. 618-628. 2009


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The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor. The author is not responsible for the contents of any external sites that are linked to in this blog


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