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Background - Digitized (scanned) medical records have been seen as a means forhospitals to reduce costs and improve access to records. However, clinical usability of digitized records can potentially have negative effects on productivity.Methods - Data were collected during follow-up outpatient consultations in two NHS hospitals by non-clinical observers using a work sampling approach in which predefined categories of clinician time usage were specified. Quantitative data was analysed using two-way ANOVA models and the Mann-Whitney U test. A focus group was held with clinicians to qualitatively explore their experiences using digitized medical records. The quantitative and qualitative results were synthesized.Results - 406 consultations were observed. Using paper records, there was a significant difference in consultation times between hospitals (p=0.016) and a significant difference in consultation times between specialties within hospitals (p=0.003). Using digitized records there was a significant difference in consultation times between specialties within a hospital (p=0.001). Excluding outliers, there was no significant difference between consultation times using digitized records compared with consultations using paper records in the same hospital, either at site (p>=0.285) or specialty level (p>=0.122). With digitized records at site A, two out of three specialties showed a significant increase in time spent searching computer records (pConclusions - Digitized medical records can be implemented without detrimentaloperational impact. Inherent differences between specialties can outweigh thedifferences between paper and digitized records. Clear and consistent operational processes are vital for the reliability and usability of digitized medical records. Divergent views about usability (such as whether patient summary information is better or worse) may reflect familiarity with features of the digitized record.

I read with interest the comprehensive review by Fawdry et al.1 Many of the issues resonate with management of general hospital notes, while some are specific to maternity notes. Recent advances in management of records offer some glimmer of hope. The authors say “paperless” offices benefit only those “logged on in one place for most of the time”. Session mobility is now being delivered in the clinical environment – this allows a session to be suspended on a given PC (free to be used by others) and to be opened again seamlessly on another PC.2 Secondly, many believe that a slavish transition to fully electronic data will lose some of the narrative and richness inherent in the paper record. We have scanned 750,000 volumes of general hospital and 70,000 maternity records, and both are now available to view electronically. Although not structured, this allows colleagues to view records simultaneously across sites and to seamlessly view data from other specialties relevant to the care of the patient. Finally, Portsmouth have implemented a digital pen solution allowing hand written forms to be completed at the ante-natal contact, data to be transferred securely via Blackberry and then entered into the maternity system at the hospital Trust.3 The ability to continue to produce and store images of paper using Document Management Systems appears to be gathering traction for preserving the richness of complex records. Fawdry et al. clearly speak with authority on the absence of standardization in maternity records. Standards for records in secondary care have been produced, but these are not widely implemented.4 In their absence, a more pragmatic approach to electronic patient records is developing using scanned records, session mobility and novel data collection. Informed discussion on these issues is more crucial than ever.