Paper-Based Versus Electronic Medical Record Keeping Essay

Custom Student Mr. Teacher ENG 1001-04 27 October 2016

Paper-Based Versus Electronic Medical Record Keeping

For many years, physicians’ offices documented all data in paper-based medical charts. Now, the physician or clinician records the medical data into a computer. Information stored in this manner is known as an electronic-based medical record or EMR. By definition, an EMR is a computerized record of the important health information regarding a patient including the care of that individual and the progress of that patient’s condition (Bonewit-West, Hunt, & Applegate, 2009). The use of computers in physicians’ offices is not new. For decades, physicians have used computers and practice management software primarily to schedule appointments and for billing. The government has offered physicians incentives designed to encourage the adoption of electronic medical records to promote medical information accessibility, better patient care, greater efficiency, and financial savings (Hamilton, 2010). In the face of advancing technology, small medical offices must compare the cost, ease of use, and maintenance of electronic medical record systems versus paper-based record keeping.

The cost of keeping paper-based and electronic medical records is not just about the actual price tag of the record-keeping systems. The cost of keeping an electronic medical record system (EMR) begins with the initial purchase and implementation of the hardware and EMR software. There are also ongoing maintenance expenses, loss of revenue associated with temporary loss of productivity due to converting paper charts to electronic ones, and the training of the staff (Menachemi & Collum, 2011). The way these record systems are stored is very different and can greatly affect the cost as well. EMR records are stored on a server, digitally, in a secure computer database within the office practice (Hamilton, 2010). On the other hand, the cost of keeping a paper-based medical record requires certain supplies. File folders, folder labels, chart dividers, paper, and writing instruments are needed. Shelves are commonly used to hold and organize the charts for ease of accessibility by the staff. A growing medical practice may often require many shelving units that take up valuable office space. Storage boxes are required to store outdated charts or charts no longer in use (Bonewit-West et al., 2009).

If there is not enough space in the office, then physicians may often have to pay for off-site storage (Hamilton, 2010). The process of using a paper-based medical record system is relatively easy. However, there are some factors to consider. To use a paper chart, the medical staff must locate and retrieve it, make sure the appropriate documents accompany the chart, and have it ready for the physician. The physician or the medical staff must allocate enough time to accurately document the chart for each patient. Any chart, whether it is paper or electronic, needs to be comprehensible, so clear writing is imperative when recording using a paper chart (Bonewit-West et al., 2009). Meanwhile, using an EMR system requires the use of a computer. This can be a desktop model, laptop, or a tablet type device. The patient records are kept digitally within the EMR system and are accessed via the computer. This type of record-keeping system does not require the addition of paper documents. All paper documents are scanned into the EMR system or electronically obtained from other pertinent sources.

Once paper documents are scanned into the EMR system, they become part of the patient’s permanent record and are no longer needed. This process requires EMR training of the medical staff, which is normally performed by the vendor supplying the EMR software. The physician and the medical staff must learn how to operate the new system and acclimate to the new paperless charting method. Learning an EMR program and using it with ease can take several months or more (Bonewit-West et al., 2009). The ease of use with both of these systems differs in the fact that paper-based records need to be filed properly in order to locate them when needed. Filing can be very time-consuming and paper-based records can be easily lost or destroyed. Even though electronic records are stored digitally on a server within the medical office, the medical staff will still need to enter the patient data into the EMR system. Electronic records need to be backed up daily because they can be lost due to failure of the hardware (Hamilton, 2010). Regular maintenance is required for both paper-based and electronic record keeping.

The maintenance differs greatly between the systems and is ongoing regardless of which system is being used in the medical office. The routine maintenance of an electronic medical record system requires hiring network professionals to monitor and maintain the network. Some examples of maintenance tasks may include performing data backup once every twenty-four hours, storing a database backup offsite, and archiving backup media once every month. There is also maintenance on the hardware and software. Hardware must be replaced and software will have to be upgraded regularly. A product specialist may need to run utilities for different applications within the EMR system. There will be ongoing training for all users of the electronic medical records system (Menachemi & Collum, 2011). In contrast to electronic medical records, maintenance of paper charts require that they are examined periodically to make sure the chart remains in good condition since these charts will become worn over time. The charting of each patient should be complete, legible, and performed in a timely fashion.

Paper charts that are outdated, that are deemed inactive or charts of patients who expired will have to be placed in boxes and put into storage (Hamilton, 2010). There are vast differences between paper-based and electronic medical record-keeping systems. One system is entirely manual while the other requires manual data entry combined with computerization. For decades, physicians and staff of medical practices have used only the manual or paper-based method of keeping medical records. Change can be costly and frustrating, but with the advancement of technology, coupled with the government requiring the use of EMR, small medical offices must explore the cost, ease of use, and maintenance involved in making this important change in the way of keeping medical records.

References
Bonewit-West, K., Hunt, S. A., & Applegate, E. J. (2009). The medical record. In Today’s Medical Assistant: Clinical & Administrative Procedures. St. Louis, Mo: Saunders/Elsevier. Hamilton, B. (2010). Electronic health records (2nd ed.). New York, NY: McGraw-Hill Higher Education. Menachemi, N., & Collum, T. (2011). Benefits and drawbacks of EHR’s. Risk Management and Healthcare Policy, 4, 47-55. Retrieved from doi:10.2147/RMHP.S12985.

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