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A colorimetric polydiacetylene (PDA) paper strip sensor that can specifically recognize Bacillus thuringiensis (BT) HD-73 spores is described in this work. The target-specific aptamer was combined with PDA, and the aptamer-conjugated PDA vesicles were then coated on polyvinylidene fluoride (PVDF) paper strips by a simple solvent evaporation method. The PDA-aptamer paper strips can be used to detect the target without any pre-treatment. Using the paper strip, the presence of BT spores is directly observable by the naked eye based on the unique blue-to-red color transition of the PDA. Quantitative studies using the paper strip were also carried out by analyzing the color transitions of the PDA. The specificity of this PDA sensor was verified with a high concentration of Escherichia coli, and no discernable change was observed. The observable color change in the paper strip occurs in less than 1 h, and the limit of detection is 3 &times, 107 CFU/mL, much below the level harmful to humans. The PDA-based paper sensor, developed in this work, does not require a separate power or detection device, making the sensor strip highly transportable and suitable for spore analysis anytime and anywhere. Moreover, this paper sensor platform is easily fabricated, can be adapted to other targets, is highly portable, and is highly specific for the detection of BT spores.

Vaccination rates of children in the United States remain below the target coverage levels identified in the Healthy People 2020 objectives. Given the success of pharmacists in providing adult vaccinations and the accessibility of pharmacists to the public, expanding pharmacists' authority to vaccinate children may improve vaccination rates of children, particularly in key disease states. This article serves as a Position Statement of the Pediatric Pharmacy Advocacy Group (PPAG), who supports the expansion of pharmacists' authority to vaccinate children. PPAG also believes that increased use of state vaccination registries by pharmacists will help improve communication and documentation of vaccines between providers. PPAG also recommends that continued education and maintaining current knowledge of vaccines and vaccine schedules are vital for pharmacist immunizers. Finally, PPAG believes that pharmacists should be advocates for childhood vaccinations.

Purpose An important goal of medical education is to teach students to use an electronic health record (EHR) safely and effectively. The purpose of this study is to examine medical student accounts of EHR use during their core inpatient clinical clerkships using a national sample. Paper health records (PHRs) are similarly examined. Method An online survey about health record use within the inpatient component of six core clerkships was administered to medical students after they completed Step 2 Clinical Knowledge of the United States Medical Licensing Examination. The sample included 17,202 U.S. medical students graduating between 2012 and 2016. Mean percentages of clerkships in which students engaged in various health record activities were computed, and analysis of variance was used to examine differences. Results The mean percentages of clerkships in which a student accessed or entered information into an EHR increased from 78% to 93% and 59% to 72%, respectively. For students who used an EHR, the mean percentage of clerkships in which they entered information remained constant at 76%. Students entered notes during the majority of their clerkships, with increases over time. However, students entered orders in less than a quarter of their clerkships, with decreases over time. The percentage of clerkships in which students used PHRs was lower and declining. Conclusions Although students used an EHR in the majority of their inpatient core clerkships, they received limited educational experiences related to order and note writing, which could translate into a lack of preparedness for future training and practice.

IntroductionPractice-based research networks (PBRNs) are sustained collaborations between healthcare professionals, researchers and members of the community that develop, conduct and report on research relevant to local needs. While PBRNs have traditionally been focused towards primary care practices and their patients, there has been increasing interest in how they may help facilitate healthcare integration. Yet, little is known on the ways in which PBRNs can best integrate with the broader healthcare system, in particular Advanced Health Research and Translation Centres. The overall project aim is to build a sustainable collaboration between a PBRN and an Advanced Health Research and Translation Centre to generate a research platform suitable for planning, undertaking and translating research to improve care across the healthcare continuum.Methods and analysisWe will use a developmental evaluation design. Our iterative approach will be informed by a programme logic model and consists of: preparation work (pre-implementation assessment, literature review, community and stakeholder engagement), adaptation and building for a sustainable collaboration (strategy for recruitment and sustainment of members) and planning for network action (designing and implementing priority initiatives, monitoring and follow-up).Ethics and disseminationThis project was approved by the Monash Health ethics committee (ERM Reference Number: 76281; Monash Health Ref: RES-21-0000-392L) and the Monash University Human Research ethics committee (Reference Number: 29786). Dissemination will take place via various channels, including relevant national and international committees and conferences, peer-reviewed journals and social media. Continuous dissemination to and communication with all participants in this project as well as other relevant stakeholders will help strengthen and sustain the network.

We developed a paper-based analytical device (μPAD) combined with self-signaling polydiacetylene (PDA) liposomes for convenient visual neomycin detection. The simple dot array type of μPAD was fabricated by the wax printing technique, and the PDA liposomes in the aqueous solution were facilely immobilized onto the hydrophilic dot region of the paper substrate. We found that, when the PDA liposomes were inserted to the paper matrix, the stability of the PDA liposomes can be significantly enhanced by adding a hydrophilic reagent such as polyvinyl alcohol and glycerol to the liposome solution. In particular, polyvinyl alcohol (PVA) provides the best stabilization among the various hydrophilic reagents tested in this contribution, and the enhanced stability sharply increased the sensitivity of the PDA liposomes in the paper matrix. Based on the above results, we successfully detected neomycin through both naked-eye observation and fluorescence measurement of PDA signals. The detection limit was 1 ppm and was selective to non-aminoglycoside antibiotics.

SummaryWith the adoption of Computerized Patient Order Entry (CPOE), many physicians – particularly consultants and those who are affiliated with multiple hospital systems – are faced with the challenge of learning to navigate and commit to memory the details of multiple EHRs and CPOE software modules. These physicians may resist CPOE adoption, and their refusal to use CPOE presents a risk to patient safety when paper and electronic orders co-exist, as paper orders generated in an electronic ordering environment can be missed or acted upon after delay, are frequently illegible, and bypass the Clinical Decision Support (CDS) that is part of the evidence-based value of CPOE.We defined a category of CPOE Low Frequency Users (LFUs) – physicians issuing a total of less than 10 orders per month – and found that 50.4% of all physicians issuing orders in 3 urban/suburban hospitals were LFUs and actively issuing orders across all shifts and days of the week. Data are presented for 2013 on the number of LFUs by month, day of week, shift and facility, over 2.3 million orders issued.A menu of 6 options to assist LFUs in the use of CPOE, from which hospital leaders could select, was instituted so that paper orders could be increasingly eliminated. The options, along with their cost implications, are described, as is the initial option selected by hospital leaders. In practice, however, a mixed pattern involving several LFU support options emerged. We review data on how the option mix selected may have impacted CPOE adoption and physician use rates at the facilities. The challenge of engaging LFU physicians in CPOE adoption may be common in moderately sized hospitals, and these options can be deployed by other systems in advancing CPOE pervasiveness of use and the eventual elimination of paper orders.

Purpose: The adoption of electronic medical record (EMR) system is gradually increasing. However, various time-motion studies reveal conflicting data regarding time effectiveness on workflow due to computerization. One of the major issues for physicians is their uncertainty with EMRs' potential impact of time on workflow. A tertiary eye hospital in south India was in the process of implementing an EMR system in their ambulatory care unit. Many of the staff did not have previous computing experience and there were conflicting views on the time effectiveness of the computerized system after implementation. The management was thus interested to know the real time effectiveness of EMR in their hospital. The study compliments existing studies of this type by comparing the time efficiency of documentation time using EMR system with paper documentation in a hospital in a developing country where a transition between paper and EMR documentation was currently in progress. Methods: Ten randomly selected optometrists documented the time they spent during consultation with both paper and EMR documentation. The time spent was documented for a total of 200 records (100 EMR and 100 paper records). The independent-samples t-test and analysis of variance were used to compare the means of the consultation time and calculated documentation time spent between the electronic and paper records. Results: There was no statistically significant difference in the time spent for documentation between electronic and paper records. The mean time spent in documenting electronic records was 0.92min (95% CI -3.06 to 1.14) longer than in paper records. Conclusion: EMR systems can be adopted in eye hospitals without having significant negative impact on duration of consultation and documentation for optometrists. More time-motion studies that include ophthalmologists are however needed in order to get a more complete picture of time impact of the EMR system on clinical workflow in eye hospitals.

Qualitative observational data from strategy workshops and documents, copies of slides, and emails used for inductive qualitative analysis.

Accountable care organizations have received considerable attention as a component of health care reform and have been specifically addressed in recent national legislation and demonstration projects by CMS. The role or roles of radiologists in such organizations are currently unclear, as are changes to the ways in which imaging services will be delivered. The authors review concepts fundamental to accountable care organizations and describe roles for radiologists that may facilitate their success in such health care delivery systems.

The internal audit activity must be independent, and internal auditors must be objective in performing their work. The chief audit executive must report to a level within the organization that allows the internal audit activity to fulfill its responsibilities. The chief audit executive must confirm to the board, at least annually, the organizational independence of the internal audit activity. The chief audit executive must communicate and interact directly with the board. The chief audit executive must report periodically to senior management and the board on the internal audit activity’s purpose, authority, responsibility, and performance relative to its plan and on its conformance with the Code of Ethics and the Standards. Reporting must also include International Standards for the Professional Practice of Internal Auditing (Standards). Significant risk and control issues, including fraud risks, governance issues, and other matters that require the attention of senior management and/or the board.

To compare accuracy and speed of keyboard and mouse electronic health record (EHR) documentation strategies with those of a paper documentation strategy.Prospective cohort study.Three documentation strategies were developed: (1) keyboard EHR, (2) mouse EHR, and (3) paper. Ophthalmology trainees recruited for the study were presented with 5 clinical cases and documented findings using each strategy. For each case-strategy pair, findings and documentation time were recorded. Accuracy of each strategy was calculated based on sensitivity (fraction of findings in actual case that were documented by subject) and positive ratio (fraction of findings identified by subject that were present in the actual case).Twenty subjects were enrolled. A total of 258 findings were identified in the 5 cases, resulting in 300 case-strategy pairs and 77 400 possible total findings documented. Sensitivity was 89.1% for the keyboard EHR, 87.2% for mouse EHR, and 88.6% for the paper strategy (no statistically significant differences). The positive ratio was 99.4% for the keyboard EHR, 98.9% for mouse EHR, and 99.9% for the paper strategy (P .001 for mouse EHR vs paper; no significant differences between other pairs). Mean ± standard deviation documentation speed was significantly slower for the keyboard (2.4 ± 1.1 seconds/finding) and mouse (2.2 ± 0.7 seconds/finding) EHR compared with the paper strategy (2.0 ± 0.8 seconds/finding). Documentation speed of the mouse EHR strategy worsened with repetition.No documentation strategy was perfectly accurate in this study. Documentation speed for both EHR strategies was slower than with paper. Further studies involving total physician time requirements for ophthalmic EHRs are required.

Vaccination rates of children in the United States remain below the target coverage levels identified in the Healthy People 2020 objectives. Given the success of pharmacists in providing adult vaccinations and the accessibility of pharmacists to the public, expanding pharmacists' authority to vaccinate children may improve vaccination rates of children, particularly in key disease states. This article serves as a Position Statement of the Pediatric Pharmacy Advocacy Group (PPAG), who supports the expansion of pharmacists' authority to vaccinate children. PPAG also believes that increased use of state vaccination registries by pharmacists will help improve communication and documentation of vaccines between providers. PPAG also recommends that continued education and maintaining current knowledge of vaccines and vaccine schedules are vital for pharmacist immunizers. Finally, PPAG believes that pharmacists should be advocates for childhood vaccinations.

This is the first in a series of papers reporting Sustainability in Health care by Allocating Resources Effectively (SHARE). The SHARE Program is an investigation of concepts, opportunities, methods and implications for evidence-based investment and disinvestment in health technologies and clinical practices in a local healthcare setting. The papers in this series are targeted at clinicians, managers, policy makers, health service researchers and implementation scientists working in this context. This paper presents an overview of the organisation-wide, systematic, integrated, evidence-based approach taken by one Australian healthcare network and provides an introduction and guide to the suite of papers reporting the experiences and outcomes.

As I am writing this editorial, the United States is preparing for the presidential election. I have no appetite to talk about this particular election, but I would like to share some of my thought...

Registration of RCTs

In order to restore confidence in financial statements the European Commission proposes different measures to enhance audit quality. This paper examines potential effects of selected proposals on audit quality in the light of prior research findings. It concludes that an increased emphasis on substantive audit procedures may not be beneficial and that joint audits potentially improve competition and audit quality, but might increase audit fees. An appointment by a third party would strengthen auditor independence. The overall impact of a mandatory rotation of audit firms is unclear due to opposite effects on auditor competence and auditor independence. The provision of non-audit services might affect independence in appearance negatively. However, a total ban would not be necessary. Finally, a limit to the proportion of fees an audit firm can receive from a single client as well as a capping of non-audit fees seem to be desirable.

Purpose Over 20 years ago the term non-specific low back pain became popular to convey the limitations of our knowledge of the pathological source of most people's low back pain. Knowledge of underlying pathology has advanced little since then, despite limited improvements in outcomes for patients with low back pain. Methods This paper discusses potential misunderstandings related to diagnostic studies in the field of low back pain and argues that future diagnostic studies should include and investigate pathological sources of low back pain. Results Six potential misunderstandings are discussed. (1) Until diagnosis is shown to improve outcomes it is not worth investigating; (2) without a gold standard it is not possible to investigate diagnosis of low back pain; (3) the presence of pathology in some people without low back pain means it is not important; (4) dismissal of the ability to diagnose low back pain in clinical guidelines is supported by the same level of evidence as recommendations for therapy; (5) suggesting use of a diagnostic test in research is misinterpreted as endorsing its use in current clinical practice; (6) we seem to have forgotten the 'bio' in biopsychosocial low back pain. Conclusions We believe the misunderstandings presented in this paper partly explain the lack of investigation into pathology as an important component of the low back pain experience. A better understanding of the biological component of low back pain in relation, and in addition, to psychosocial factors is important for a more rational approach to management of low back pain.

With the United States national goal and incentive program to transition from paper to electronic health records (EHRs), healthcare organizations are increasingly implementing EHRs and other related health information technology (IT). However, in institutions which have long adopted these computerized systems, such as the Veterans Health Administration, healthcare workers continue to rely on paper to complete their work. Furthermore, insufficient EHR design also results in computer-based workarounds. Using direct observation with opportunistic interviewing, we investigated the use of paper- and computerbased workarounds to the EHR with a multi-site study of 54 healthcare workers, including primary care providers, nurses, and other healthcare staff. Our analysis revealed several paper- and computer-based workarounds to the VA’s EHR. These workarounds, including clinician-designed information tools, provide evidence for how to enhance the design of the EHR to better support the needs of clinicians.

AimsTo audit the new pharmacist-led telephone service for warfarin dosing and monitoring of INR, and compare it to the previous system. The previous system was based on the paediatric cardiology ward, dosing by junior medical staff to dose and documented on a paper system. Also to audit the parent satisfaction of the new system.MethodsSearch the computerised system to reveal 73 patients on warfarin with a total of 1547 INRs, and looked for any complications or out of range results. This to be compared to a previous audit of the original system of 44 patients on warfarin with a total of 1289 INRs.For parent/carer satisfaction, a questionnaire was sent to parents/carers of all patients who were under the care of the pharmacist-led children's warfarin clinic.ResultsThe pharmacist-led children's warfarin service was fully compliant for NPSA safety standards for warfarin dosing. There was no significant difference in the safety indicators from the original service and the pharmacist-led service.11 patients (25%) were lost to follow up from the original service, compared to none in the pharmacist-led service. No patients from either service had an inappropriate target INR and every patient had been given the correct information. 38 out of 53 (72%) parents/carers returned the satisfaction survey. 28 (78%) reported that their overall experience of the clinic was excellent and the rest found it satisfactory.DiscussionChanging to the pharmacist-led service has meant that it is now compliant with NPSA standards and the safety indicators are comparable to the original service. The service has generally been very well received, with all parents/carers finding the service at least satisfactory and 78% found it excellent. The pharmacist-led service is unique, as it uses a computerised system for documentation, with the aim to produce a paediatric dosing algorithm.

The World Health Organization (WHO) Stop TB Strategy calls for involvement of all healthcare providers in tuberculosis (TB) control. There is evidence that many people with TB seek care from informal providers before or after diagnosis, but very little has been done to engage these informal providers. Their involvement is often discussed with regard to DOTS (directly observed treatment - short course), rather than to the implementation of the comprehensive Stop TB Strategy. This paper discusses the potential contribution of informal providers to all components of the WHO Stop TB Strategy, including DOTS, programmatic management of multi-drug-resistant TB (MDR-TB), TB/HIV collaborative activities, health systems strengthening, engaging people with TB and their communities, and enabling research.The conclusion is that with increased stewardship by the national TB program (NTP), informal providers might contribute to implementation of the Stop TB Strategy. NTPs need practical guidelines to set up and scale up initiatives, including tools to assess the implications of these initiatives on complex dimensions like health systems strengthening.

Aim: Electronic health record (EHR) data have great potential for reuse in research and patient care quality improvement initiatives. However, in dual systems, where both electronic and paper health records are used, inconsistencies and errors may occur. The objective of this study was to determine the degree of agreement between EHR clinical data and paper records for reuse in clinical oral health research and quality improvement initiatives. Methods: A random sample of 200 EHRs for adolescents from eight Area Health Services was obtained from the Information System for Oral Health New South Wales database of 29 599 records, and compared with 200 paper records for adolescents that were stored at clinics. The records were analysed for data reliability. The electronic records were percentage weighted to reflect the number of adolescents treated in each of the Area Health Services. Results: The results showed an overall 95.0% agreement between the 200 individual EHRs and the 200 clinic-stored paper records. In 1.5% of cases, information contained in the paper record was not uploaded into the EHR, and in 3.5% of cases, information contained in the EHR was missing from the paper record. Conclusions: It is possible to conclude that more deficiencies occurred in paper records compared with EHRs. These deficiencies should be taken into account if EHRs are to be reused for clinical oral health research or quality improvement initiatives. Considering the missing data and the great strides in information system technology, it would be logical to adopt one system, with a focus on electronic records to replace the paper records.

Recognizing the need for greater attention worldwide to noncommunicable diseases (NCDs) such as cardiovascular disease and diabetes, implementers are increasingly putting NCD programs in place. This effort is yielding practice-based experiences and evidence that may not be systematically documented and shared, reflected in a limited body of peer-reviewed and gray literature and few platforms for knowledge exchange. To draw on such knowledge that is grounded in experience, we gathered information through reviews of literature, local needs assessments, technical dialogues at the national and local levels, and structured global stakeholder engagement events to yield four principles that reflect the current state of knowledge on developing and implementing community-based services for health promotion and disease management: (1) Support and empower people living with chronic disease to provide better self-care and advocate for improved services. (2) Invest in integrating NCDs into existing development platforms but do not underestimate true costs and effort. (3) Engage a broad range of front-line health workers to champion care. (4) Build coalitions to leverage the strengths of both the public sector’s and private sector’s capacity and leadership. If applied consistently by funders and implementers, these principles have the potential to accelerate progress in reaching low-resourced communities with NCD care and treatment services. At the same time, if implementers commit to proactively, transparently, and collaboratively sharing experience-based learning, the NCD movement will not only pick up speed and be well supported by evidence but will also benefit from programmatic, financial, and political synergies at the global, national, and local levels.

Summary Purpose: To assess the utility of personal digital assistants for documentation at the bedside on an acute pain service. Methods: This reality-based unblinded randomized trial recruited 35 patients on the personal digital assistant (PDA) arm and 39 patients on the paper arm. The primary outcome measure was assessment time and comprehensiveness between patient visits documented on paper versus the PDA. Secondary objectives were to gather qualitative information about the use of PDAs at the point-of-care. Results: The median time to complete the initial patient assessment was 2.8 min on the PDA arm and 2.7 min on the paper arm. The median total patient encounter time (assessment and recording) was 6.1 and 4.6 min on the PDA and paper arms, respectively ( Z = −2.28, P -value = 0.00). Pain scores were documented on 65% of assessments on the PDA arm and 44% of the assessments on the paper arm. Nausea, pruritis and sedation were collected on 100% of PDA assessments, compared to 13–33% of paper assessments. Conclusions: This study found that patient encounter time was longer but more information was collected on the PDA compared to paper. Non-PDA owners took significantly longer to document on the PDA compared to paper.

Introduction: Inconsistent and poorly structured content in admission and discharge notes can lead to adverse clinical incidents. Structured medical records improve health care professional performance, patient outcome and quality of information available for audit and research. A structured obstetric specific admission and discharge proforma was introduced to our obstetric high dependency unit (HDU) with the aim of improving patient safety. The admission sheet documents basic demographics, diagnosis, mode of delivery and specific monitoring requirements. The discharge section includes a tick-box systems review, investigation summary and ongoing treatment plan. We audited the impact of the proforma on the adequacy of information documented in HDU notes. Methods: Case notes of mothers admitted to HDU prior to proforma introduction were retrospectively reviewed for recording of information requested on the new standardised medical record. A program of education emphasising practical use and importance of completion accompanied the introduction of the proforma. A prospective case note review of mothers was then completed using solely the admission and discharge proforma for information collection. Results: 20 case notes were reviewed prior to introduction and 10 case notes after.

In a disease outbreak, medication must be rapidly yet safely distributed to a population. Are there significant differences in efficiency (time) and error rates in drug dissemination to a population using algorithm-driven paper and personal digital assistant (PDA) methodology? In this study, conducted at the University of Hawaii, mock citizens were sent through points of dispensing with volunteer clerks processing them during two sessions (alternating modes for Session 2). No significant differences were found in time or number of errors with PDA vs. paper. However, the mode and order of testing affected time. Clerks doing the paper method second were slower than those doing paper first (significant at p < 0.0001 level). The PDA was consistent in time whether clerks used it first or second. This may indicate the presence of a fatigue factor from using the paper method and may indicate that during an outbreak, when clerks are tired, using an algorithm-driven PDA may help sustain efficiency.

There is a need to develop an accreditation process for South African physicians who practise perioperative echocardiography. International level accreditation will bring legitimacy to the process of training practitioners in perioperative echocardiography and ensure standards of practice. Accreditation will be developed as a two-year process during which candidates with a College Fellowship or MMed degree may register with a supervisor and submit a portfolio of 120 comprehensive echo reports and five complete digital studies for assessment. If these are judged to be of an adequate standard, the candidate will be eligible to sit an exam consisting of a multiple-choice question theory and echo video paper and an oral exam.

The CONSORT statement for the full reporting of clinical trials should be consistently applied Although current European League Against Rheumatism (EULAR)1 and American College of Rheumatology (ACR)2 guidelines both support paracetamol (acetaminophen) as the first line oral analgesic for patients with knee osteoarthritis (OA), until now there has been a paucity of clinical trial data to confirm the efficacy of paracetamol in large joint OA. This issue of the Annals is unique in containing one meta-analysis and two large placebo controlled studies that examine evidence for the efficacy of paracetamol in OA. Never in the 127 years of paracetamol’s existence have so much trial data on OA been reported. Because of the marked placebo effect in pain trials3 comparison with a placebo is clearly important to determine the true efficacy of any analgesic. Therefore it is surprising that despite the widespread use and support of paracetamol in OA until now there have been only four placebo controlled trials of this drug in OA. The first two studies reported in 19834 and in 19955 both demonstrated the superiority of paracetamol over placebo for pain relief in large joint OA using parallel group designs. However, the first study contained only 25 patients with knee OA followed up for just 6 weeks.4 The second study was larger (60 patients) but was of just 1 week’s duration and contained a mixed population with knee or hip OA.5 A third parallel group study was reported in 2003.6 This compared paracetamol, diclofenac, and placebo over a 12 week period in 82 patients with knee OA but was the first negative study for paracetamol, showing no difference between paracetamol and placebo using Western Ontario McMaster Osteoarthritis Index (WOMAC) assessments. Most recently, Pincus et al carried out a crossover study …

Background It has been shown that implementation of electronic medical records (EMR) and withdrawal of the paper-based medical record is feasible, but represents a drastic change in the information environment of hospital physicians. Previous investigations have revealed considerable inter-hospital variations in EMR system use and user satisfaction. The aim of this study was to further explore changes of clinicians' work after the EMR system implementation process and how they experienced working in a paper-deprived information environment. Methods Qualitative study based on 18 semi-structured interviews with physicians in two Norwegian hospitals. Results Ten different but related characteristics of work within the EMR-based practice were identified; (1) there was closer clinical and administrative cooperation during the implementation processes; (2) there were greater benefits when everybody used the system; (3) systems supported freshmen better than experienced physicians; (4) the EMR was useful in regard to professional learning; (5) new users were given an introduction to the system by experienced; (6) younger clinicians reported different attitudes than senior clinicians, but this might be related to more than age and previous experience with computers; (7) the EMR made it easier to generate free-text notes, but this also created a potential for information overflow; (8) there is little or no support for mobile work; (9) instances of downtime are still experienced, and this influenced the attitude towards the system and (10) clinicians preferred EMR-only compared to combined paper and electronic systems. Conclusion Despite the removal of paper-based records from clinical workflow (a change that hospital clinicians perceived as highly useful), many of the old routines remained unchanged, limiting the potential of the EMR system. Thus, there is a need to not only remove paper in the physical sense, but also to established routines to fully achieve the benefits of an EMR system.