There was once a time not too long ago that every record your doctor kept was paper-based. Not only was this cumbersome, but it could lead to gaps in information between clinicians, which could compromise patient care.

Healthcare is evolving in a way that allows providers to collect an unprecedented amount of data at an unprecedented rate of speed. This data goes beyond patient care records used by physicians to include information collected and used by ancillary departments across a practice or hospital, such as billing and payroll.  But if this vast data is not collected, managed and made accessible in a way that meets the needs of physicians, administrators and patients, then what good is it?

This three-part series will examine the shift from paper-based record keeping to electronic health records, or EHR, and ultimately to more complex information management such as enterprise content solutions.

Part 1: Electronic Health Records and Document Management and Imaging

As recently as 10 years ago, hospitals and physicians were mostly using paper-based systems. However, as the internet, computers and other record-keeping technologies became less expensive and widely available; hospitals began to utilize computerized order entry systems (CPOE). Computerized physician order entry (CPOE), sometimes referred to as computerized provider order entry or computerized provider order management (CPOM), is a process of electronic entry of medical instructions by the physician for the treatment of patients (particularly hospitalized patients) under his or her care.

When first introduced, CPOE helped hospitals reduce delays in order distribution, resource allocation and order completion while reducing errors related to bad handwriting. These systems also allowed physicians to order services at the point of care, reduce duplicate tests and incorrect doses, and simplify posting of service charges for the patient.

The center of this records system was Document Management and Imaging (DMI). Beginning in the 1980s, a number of vendors began to develop software systems to manage paper-based documents. These systems dealt with paper documents, which included not only printed and published documents, but also photographs and prints, such as from imaging tests. DMI enabled a hospital to capture faxes and forms, save copies of the documents as image files, and to store those image files in a repository with secure, fast retrieval.