Though the government has been trying to increase electronic paperless systems for clinical record keeping since 1998, a fully paperless NHS remains a distant reality.
Four out of five NHS trusts continue to use pen and paper, and many claimed their transition was "ongoing".
An investigation by The BMJ using freedom of information (FOI) requests found that just 39 of 184 NHS trusts in England (21%) reported use of paperless systems to document clinical notes.
Just a quarter (45) reported using fully electronic systems for prescribing medications.
Despite all hospital trusts having an electronic patient record in place, 79% (145) reported that they still relied on pen and paper to some extent for documenting clinical notes.
The clinical documentation in NHS hospitals has been undergoing “digital transformation” since 1998, when the government first declared its ambition to transition from paper to electronic records with its Information Strategy for the Modern NHS.
Successive governments have tried to unlock these benefits by pledging to make the NHS paper free.
Shifting from paper to digital systems offers several potential benefits for the NHS.
Information can be shared more easily and quickly between clinicians, and patient data can be stored more securely with encryption and access controls.
Electronic patient records also provide the foundation for further technological advancement, such as joining up disparate data across multiple healthcare organisations.
The FOI data also show that many trusts use multiple electronic systems to record patient notes. Of the 156 trusts that cited the specific electronic system they used, nearly a third (49) were using two or more programmes.
