Advantages and disadvantages of computer-based versus paper-based medical records

¶ … computer-based vs. paper-based medical records, and discuss which are better. Record-keeping is an important and vital part of any medical practice. Keeping medical records ensures the health and wellness of patients by tracking their overall care and health history. Record-keeping is important for many purposes including legal information, health information and documentation, and keeping information that must be shared for professionals that are documented caregivers for patients. Thus, determining the best method for keeping records is vital to the patient and clinics success.

Keeping paper-based medical records has been the standard for some time. Paper records provide a wealth of information. Only recently has the computer been seen as an effective tool for keeping medical records. Computers are now considered a confidential and safe tool for keeping medical records. There are many advantages of computer-based medical records. Computers have the ability to store a lifetime of health data in a manner that allows multiple users to access this data simultaneously (Shortliffe & Perreault, 2001). The Medical Record Institute states that clinical data held in a repository and integrated by many different sources is clinically characterized as a computer-based health record (Tange, 1999) which can link many different knowledge sources at one time. A clinical data system as this can allow linkage with many different health providers for healthcare support decisions and the collection of aggregate data (Shortliffe & Perreault, 2001). A physician can access this information from many different locations, even from their home in emergencies, and manipulate data in many different ways. Sampling and surveys can also be conducted online using data collected from medical records. Patient decision making and health promotion is also more easily managed with computer-generated medical records.

Of course, many healthcare providers are simply more accustomed to paper medical records. Paper medical records provide simple and easy-to-use checklists. They require very little training. Many traditional nurses and caregivers are accustomed to using paper medical records, which are inexpensive and easy to store and carry from place-to-place. Some argue that clinicians and medical managers suggest that individuals do not adapt well to change, and would prefer to stick with traditional methods of documentation which include paper records (Lovis, Baud & Planch, 2000). Medical narratives are easily transcribed from thought to paper, although they are just as easily transcribed into a computer medical record.

Is one better than the other? Some suggest a combination of paper and computer-generated medical records provide the most advantages for individuals. Paper records naturally require physical storage space. However there are also drawbacks to computer-based medical record keeping, including upkeep and maintenance. If a computer system goes down, this could prevent physicians and caregivers from retrieving the information they need. One disadvantage of computer-based records is the possibility of a records-breech or leak of confidentiality. There is always a chance that medical records could be accessed by someone illegally. This could cause many problems. This is not to say the same could not happen of paper medical records.

There are many advantages and disadvantages of both paper and computer-based medical records. Ultimately the decision depends on the individual and the practice handling the medical records. A combination of the two is may often be used by caregivers to provide the best possible care and provide the best documentation of patient's health history.