From Paper to EHR: A Millennial's Perspective

Evelyn B. Ling, MD, MS; Contributors: Hsien-Hwa Alice Cha, MD; Neera Ahuja, MD


February 19, 2019

Experiences as a Resident

As a millennial, technology such as smartphones and wireless connectivity is deeply integrated into my personal life, and that was my expectation in my professional life as well. My internal medicine residency had electronic health record (EHR) systems at all of its training sites. Learning how to use the EHR was a natural extension of my medical training. During rounds, as an intern presented, a resident would have the EHR open, ready to review labs, images, or notes, and to enter orders on the spot.

The EHR was invaluable in helping me understand my patients. For example, I could easily trace the progression of a patient's kidney failure by charting his creatinine values over the past few years, or review previous office visit notes describing issues or medical problems that the patient sometimes forgot to mention.

Occasionally, the EHR system would be down and the whole hospital would be paralyzed. When that happened, it felt unreal to have to walk to the patient's unit to write orders on paper. With my reliance on the options presented in EHR preference lists, I struggled to remember the doses and frequencies of medications. I was always grateful when the EHR system was back online.

A Medical 'Commune' Formed in Reviewing Paper Charts

Little did I know that after residency, I would work at a community hospital where paper charts would be a part of my daily routine. The hospital was planning to transition to an EHR about 6 months after I started, one of multiple transitions the hospital had undergone. The hospitalist group was introduced 2-3 years before I started and comprised physicians who had also finished residency around that time. Compared with those who had worked at the hospital for many years, we were physicians from a different generation, both in age and in training.

The first few weeks of my job felt as if I had traveled to a past era. At each nursing station, physicians and other providers were looking for specific patient charts and spun a metal carousel of patient binders that would groan and heave. Inevitably, the chart would be missing and we would take up time searching or pleading for the chart until a kind unit clerk or nurse helped us out. Each binder had a colored dial on the spine, with different colors indicating various tasks. For example, if the dial was turned yellow, the chart had to be reviewed by pharmacy. If the dial was turned green, it meant that the patient had discharge orders. I would have to remember to turn the dial to red or a new order would potentially be missed by the unit clerk. We also had to go to medical records to sign stacks of charts that included verbal orders or missing signatures. I learned very quickly to go weekly after spending one evening signing a month's worth of charts, nearly 70.

The ease of the paper system seemed to reflect a different generation of practice.

Our hospital used a patchwork of different computer systems to read images, write notes, and get lab results. While hospitalists typed notes in a Word document, many consultants still handwrote their notes. I learned that the stereotype of doctors having bad handwriting was rooted in truth. My eyes would strain to read the note using as many patient contextual clues as possible. When that failed, I would hand it to a unit clerk, who, through years of experience, was best at interpreting every doctor's unique "font." Occasionally, misinterpretation of handwriting led to errors, such as when a BMP (basic metabolic panel) was ordered instead of a BNP (brain natriuretic peptide).

Yet, there were some advantages of paper over EHR. The ease of the paper system seemed to reflect a different generation of practice, in which physicians were expected to do less clerical and administrative work. You could handwrite orders to specify exactly what you desired instead of being limited to the order that was directed by the system. Nurses and clerks would see the order and make it happen with few questions asked. I could simply write "obtain medical records" as an order, and a clerk would go through the process of obtaining consent, etc. Instead of copied and forwarded notes bloated with unread data, it was refreshing to read a consultant's succinct notes, with only pertinent subjective physical exam findings, lab values and assessment, and plans.

The paper charts also promoted a feeling of community. Instead of spending most of our time in isolation, we were more likely to spend time with others on the floors to access a paper chart, read a consultant's note, or write notes and orders. The nursing station became a fertile ground for spontaneous introductions or conversations with specialists, nurses, and other healthcare providers. Being new, it was a great way for me to meet everyone in the hospital. It also was more apparent when a sick patient required multiple orders, updates, and conversations with specialists.

Being around each other also gave the staff a chance to slip in encouragements on a busy day. I remember staying late one night to transfer a patient. In a touching moment, a nurse who had seen me there all day came up to tell me, "I just wanted to say you did a great job today. I saw how hard you worked."

Transitioning to EHR: Not All Found It More Efficient

Before I knew it, the time for transitioning to the EHR had arrived. Among our hospitalist group were feelings of excitement and possibility. Despite having used EHRs before, our group still went through a learning curve. We had to learn a new workflow and use new templates, but this largely replicated what we had already used during residency. Soon everything felt much more efficient. Instead of having to open multiple systems for labs and images, it was all in one place. We could read consultant notes that were once illegible. We could see and order what was in the system without calling multiple people to figure out if an order even existed.

The EHR transition felt as if it came at the expense of physicians.

By contrast, some of the other physicians struggled. Many had never used an EHR and were unaccustomed to typing or using computers in their personal lives. In addition, there was a slight culture shift. One physician told me that the EHR transition felt as though it came at the expense of physicians, because they were being asked to input more orders and were more responsible for administrative tasks, which slowed their workflow. Their frustration was palpable. Rumors spread that some doctors had outright refused to put orders into the EHR, but most did their best to navigate this new system. In a reversal of the normal order, the older doctors sought out the younger hospitalists for help, dropping by our workroom for troubleshooting, which they hadn't done before.

The EHR felt unifying, bringing all of the data (progress notes, images) together. At the same time, it seemed as though the shared physical space of paper charts was traded for impersonal electronic distance. Nurses noticed that physicians were not on the patient floors as often as they used to be. I ran into other consultants less often. We were also noticeably much more sedentary.

Some physicians commented that the instant availability of data such as lab results and images was a double-edged sword. Although it was nice to immediately access the data, some consultants complained that many patients now expected them to continue following up on data even after work. The association between the EHR burden and physician burnout became even clearer during this transition.

When I've asked people if they miss paper charts, most would not trade the EHR for paper. It is undoubtedly more efficient and natural for the physicians who have trained on it. However, for those who did not train on EHRs, it is a reminder of how medicine is changing. Documentation seems driven by billing and coding, and more administrative tasks are demanded of physicians. To them, it feels overall to be less about patient care.

The reality is that the generation of physicians who trained on EHRs don't know any other way. As one physician told me, "This is where medicine is going, so you'd better adapt and accept it or win the lottery."

How can we merge the best of the paper-chart generation with the EHR generation? How can we appreciate the efficiency of EHRs while maintaining the more personal touch of the paper charts? Is there a way to reduce physician administrative burden and avoid burnout?

Despite these lingering questions, what stood out most during the EHR transition is the sense of community within the hospital, both when I was learning how to use the paper charts and as I was initially helping older physicians learn to use the EHR. It was like a bridge between generations. If we can somehow remember to nurture our medical community and continue to help each other out in this new era of medicine, that's a start.

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