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Why we won’t have a paperless NHS anytime soon

The NHS is going digital. Slowly. After spending billions of pounds on IT projects of variable success, the aim is now for the NHS to be largely paperless by 2023.

There is no doubt that the NHS needs to digitise its paper records, and it needs to link up the disparate computer systems that hold those records. General practice has already implemented electronic records, but hospitals are proving to be a bigger challenge.

To get an idea of what a paperless NHS might look like, you can turn to the US where electronic healthcare records in hospitals are now the norm. There have certainly been benefits (records are accessible and easy to read) but also, to borrow a medical phrase, side effects.

Warning: may cause productivity paradox

Hospitals rely heavily on people working together and sharing information, but doctors feel isolated when stuck in front of a computer monitor, often tucked away in an office. Here they are less likely to have informal conversations with other healthcare professionals – the sorts of conversations that keep a ward ticking along.

Instead of saving time, doctors complain of spending longer than ever entering data, and less and less time with their patients. This so-called “productivity paradox” is leading to workarounds, both within the computer systems and alongside them. One aspect of this is known as “paper persistence” – the inability of doctors to give up the tree pulp habit.

Most doctors, working on an inpatient ward, carry an important piece of paper in their pocket: a patient list. These lists are typically neither standardised nor part of the official institutional documentation, but they exist alongside electronic medical records to support and coordinate the doctor’s work.

Obtaining and annotating this list is often the first job of the day. The patient list lets the doctor underline or add important information in an ad hoc manner. Computer systems rarely have this flexibility.

The rigidity of electronic record does not allow for nuance, and it is nowhere near as light or accessible as a sheet of A4. You don’t need a password to access it and you can fold it and pop it in your pocket when examining a patient – try to do that with a tablet computer. Paper’s utility has yet to be replicated by another technology.

As much as it has its failings, the paper record was a surprisingly adaptable and collaborative device. The appearance and size of a set of notes gave an idea of the patient’s medical history. The handwriting of a trusted colleague would pop out from the numerous written entries of a long inpatient stay. Experienced fingers, flicking through the notes, could find information efficiently, as long as it hadn’t gone missing, that is. And there’s the thing, when providing increased accessibility, quality and safety, the advantages of electronic records should outweigh the good things about paper notes.

If we are going to succeed in having a more modern, digital healthcare service, we need to design systems that work better than paper-based systems, rather than trying to squeeze paper processes into electronic records.

The digitisation of medicine is far from just being about the technology, it is also about the people using it, and how they work together. The persistence of paper alongside electronic records will continue, and should continue, until better systems – that reflect the way people actually work – can be developed to deliver safer and more timely care.

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