Electronic care record

Dr Holloway describes the moves to introduce an electronic care record (ECR) (Psychiatric Bulletin, July 2005, 29, 241-243). He raises concerns that ‘important qualitative aspects’ may be lost in the transition from existing medical records.

There is no reason to suppose that this should be the case. There is nothing contained in traditional records that cannot be easily translated to electronic form. The ‘qualitative aspects’ may be contained in free text notes or diagrams, and technology to include these is readily available. In addition, the fact that the record will be permanently accessible nationwide (and clearly legible) may encourage fuller and more informative recording than at present.

Clearly, the mechanism of entry will change from pen and paper to keyboard and mouse. This will pose no problem to the many increasingly IT-literate trainees, and for some will make data entry faster and more accurate. For everyone else, emergent technologies such as voice recognition may be appropriate or the secretarial role could be expanded to include typing of entries. Many documents (out-patient letters, minutes of meetings, etc) are already typed and held on computer, so including these in the ECR should be straightforward. There are clearly resource implications, but there will also be savings, as many labour-intensive aspects of paper notes (fetching and carrying, filing, locating records, etc) will no longer be needed.

Many trusts have already introduced some form of electronic patient record with success. None of the problems posed is insuperable, and with appropriate planning the ECR should surpass traditional medical records in every aspect.