Electronic patient records/prescribing


Having recently experienced an outage of the computer system in our trust, I thought about the use of electronic patient records and what its advantages and disadvantages are over paper records.

 

(+) The ability to do work remotely

There is no need to physically go to a ward to review notes, prescribe medications. This also means that you can review a patient's case and current progress and investigations when responding to referrals, so you can reject inappropriate ones there and then rather t


han later when you arrive on the wards.


(+) Multiple staff members can view the records at the same time

Unlike physical notes, there is no need to search for notes when someone else may have taken it away from the bedside temporarily.


(+) Clear audit trail and accountability

With the caveat of everyone using their own login and not sharing with others, entries are electronically signed and therefore we can identify which part of the process went wrong and who was involved. This also serves the purpose of protecting yourself if you have clearly documented your (justifiable) actions, as records cannot be permanently deleted once entered. There is a lot lower chance of records going missing compared to paper notes. It will also be easier to sieve through specific patient demographics when carrying out audits, e.g. the ability to perform a blanket search on all patients who had a D-dimer ordered for the past month.


(+) Systematic documentation using templates and legibility

With electronic documents and prescribing, there is the option of setting up templates to enable systematic documentation. Unlike paper notes, making some fields mandatory means that they can only be saved if the required domains are completed. This ensures crucial information are not missed, for example my trust makes VTE assessment a mandatory part of the clerking document. Additionally, compared to paper notes, there are no concerns over illegible handwriting.


(-) Reliance of functional laptops/computers

You will rely a lot on laptops and computers. System outage is one thing, but be prepared to work with slow laptops. I suspect most of them were bought in bulk at the lowest specs and never replaced for the past decade. You will spend a lot of time either trying to grab a laptop if there aren't enough around, or just repeating attempts to load the system back up after it crashes.


(-) Confidentiality concerns

With electronic patient records being stored in a server, there remains concerns that hackers may be able to steal information remotely, and this would be extremely problematic especially from a confidentiality point of view. There has been a few incidents over the years and these tend to involved breach of much larger scales than when physical records are leaked, simply because of how easy it is to export large volumes of digitised information.


TL;DR

Overall, I feel that electronic patient records provide a better quality of life for doctors and staff, while maintaining a high quality of care to patients. Provided we use it appropriately and can ensure systems remain at a high standard from the technical and security aspects, it should be a goal for more hospitals to transition towards electronic systems. The hardest part will be transition from one system to another, as I have experienced during the system outage where we had to use paper notes all of a sudden. This may simply be resolved with a staged transition process.



 

Comment below your own thoughts about electronic healthcare systems. Do you prefer paper notes instead? Let us know!

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