3089 — Paper-based Workarounds to the VA’s Electronic Health Record: Implications for Optimal Healthcare Delivery

Saleem JJ (COE - Indianapolis VAMC), Russ AL (COE - Indianapolis VAMC), Justice CF (Department of Computer Information Technology, Indiana University-Purdue University at Indianapolis (IUPUI)), Hagg H (COE - Indianapolis VAMC), Woodbridge PA (VA Nebraska Western Iowa Heath Care System), Doebbeling BN (COE - Indianapolis VAMC)

Objectives:
The objective of this study was to investigate human-technology integration factors that may be causing employees to rely on paper alternatives to the electronic health records (EHR) and understand the impact of these workarounds on optimal healthcare delivery. Even in institutions that have long adopted an EHR, like the VA, employees continue to rely on paper to complete their work. Thus, this study was designed to advance our knowledge of factors that promote the persistence of paper after EHR implementation.

Methods:
We conducted semi-structured interviews with 20 key-informants in a large VAMC, with a fully implemented EHR, the Computerized Patient Record System (CPRS), to understand the use of paper-based workarounds. Participants included clinicians, administrators, and information technology (IT) specialists across several service areas in the medical center. Two of the authors (JS and AR) independently coded the typed transcripts into distinct cases of paper-use associated with the EHR. We integrated findings across the interviews into meaningful patterns and abstracted the data into emergent themes for recurrent paper-based workaround strategies.

Results:
From 125 instances of paper use where codes were assigned, we found nine distinct categories of paper-based workarounds to the use of the CPRS. Paper use related to the following: (1) efficiency, (2) knowledge/skill/ease of use, (3) memory, (4) sensorimotor preferences, (5) awareness, (6) task specificity, (7) task complexity, (8) data organization, and (9) longitudinal data processes.

Implications:
The emergent categories of paper-based workarounds relate to the workflow, cognitive, and usability reasons individuals use paper rather than CPRS for certain healthcare delivery tasks. In several cases, paper served as an important tool and assisted healthcare employees in their work. In other cases, paper use circumvented the intended design of CPRS, introduced potential gaps in documentation, and generated possible paths to medical error.

Impacts:
Specific cases of paper-based workarounds documented in this study provide an opportunity to consider ways to support the use of important paper supplementation without introducing the potential for gaps in EHR documentation. Further, the results provide a human factors outline to innovate EHR design, particularly the VHA’s CPRS, to better support optimal healthcare delivery.