Paper Has Healthcare Spoiled

As I was thinking about the radical invention of something called paper, I realized that we’re really quite spoiled by paper and its amazing benefits. Let me just list a few of the radical benefits that paper provides a doctor using a paper chart.

* Immediate response to pen – Yes, tablets and styluses are getting better, but there’s nothing like the instant satisfaction of putting pen to paper and seeing the ink spread across the page. Sure, the pen runs out every once in a while, but that’s generally pretty rare. A nice pen just flat out works with an immediate response in the exact location you want something written. There’s no calibration needed. You just pick it up and start using it. It’s beautiful.

* Never a delay when flipping pages – Think about the beauty of paper’s ability to flip between pages. When I turn a page I get an immediate response to that flip and see the desired result (a new page) immediately. I’ve never seen an hour glass when flipping between pieces of paper. I’ve never had a page partially load and need to refresh. Paper has the unique ability to flip pages with instant display of the next page.

* Instant On – Speaking of instant, paper charts are the true epitome of “Instant On” technology. Computers are getting better at making boot times fast and computers turning on quickly. However, anyone who regularly uses a computer knows all the screens you have to see as your computer boots up. A paper chart is beautiful in its ability to immediately be available for you to work. It has true Instant On capabilities.

* No training needed – Ok, maybe this is a stretch of a title. There is no training needed for paper, because since elementary school we’ve been taught how to write with pen and paper. The ability to write is near universal thanks to training in doing so since we were children. You hand a new doctor some pen and paper and they can start documenting their visit. No login or password required. No needing to know how to access Citrix so you can open the chart. Just hand them the chart and a pen and they start charting.

* Multiple page view – The display area of paper is so expandable. If you need a dual monitor dual page view of the paper you just slide it open. If you need a quad page view, you’re only limited by the amount of desk space you have or you could even move to the floor if needed. This easy to manage multi page view is powerful since it’s quite often that you want to see multiple pages at the same time.

* Fast page switching – Take a paper chart and watch how fast you can switch back and forth between pages of the chart. I call this “thumb in chart mode.” With 5 fingers you can even instantly “bookmark” up to 5 locations in the chart which you can switch to and back very quickly with zero load time.

* Flexible to an infinite number of documentation methods – Does paper support the SOAP format? Yes! Does it support every specialty? Yes! Paper has the ability to morph to every medical specialty’s documentation needs. In fact, it can easily be adapted to a different documentation method for every doctor within every specialty. It’s designed so flexibly that there really are an infinite number of documentation methods it can support.

* Easily supports text and graphic input – Oh the beauty of paper. In the same input area you can easily add text or graphics. In fact you can easily link the text and graphics in whatever way you see fit. Some might prefer to write male or others might prefer to draw the universal symbol for male. It’s completely extensible to text or graphics in every area of the page.

I’m sure there are other areas where paper spoils us that I’ve missed, but this is a good start. Hopefully you’ll add any areas I’ve missed in the comments.

Watch for future posts in my “Healthcare Spoiled” series.

About the author

John Lynn

John Lynn

John Lynn is the Founder of the HealthcareScene.com, a network of leading Healthcare IT resources. The flagship blog, Healthcare IT Today, contains over 13,000 articles with over half of the articles written by John. These EMR and Healthcare IT related articles have been viewed over 20 million times.

John manages Healthcare IT Central, the leading career Health IT job board. He also organizes the first of its kind conference and community focused on healthcare marketing, Healthcare and IT Marketing Conference, and a healthcare IT conference, EXPO.health, focused on practical healthcare IT innovation. John is an advisor to multiple healthcare IT companies. John is highly involved in social media, and in addition to his blogs can be found on Twitter: @techguy.

37 Comments

  • Joe Frank,
    I had that in mind as well when I wrote this. I was going to post that this weekend as a follow up to this post. In fact, I have a draft waiting for it right now. Hilarious for sure.

  • A paper file’s security is really impressive, especially when it’s:

    o Been lost, misfiled, stuck in a drawer, etc.
    o Back in the office, when you’re at home
    o Being used by someone else who doesn’t give it back
    o Stained, etc.
    o Written on illegibly
    o Been erased
    o Been left open for everyone to read
    o Missing pages, reports, etc.

  • What are you talking about, Carl?

    Between 2010 and 2011, the frequency of data breaches from healthcare organizations doubled, and is expected to double again in 2012. 96% of healthcare organizations have experienced breaches of PHI in the last 2 years, and the thieves are targeting medical identities increasingly more often. What’s more, data breaches have cost the nation $64 billion in the last year.

    That didn’t happen with paper records, Carl. Paper is the gold standard in security.

  • D. Kellus Pruitt,
    There are a lot of issues with the numbers you provide. First, in the paper world we often didn’t know when something was breached. So, we had no data on when it was breached or not. Some increase in breaches was due to tech’s ability to actually know when a breach occurs. Doesn’t mean it’s actually more often.

    Second, when I looked through the list of breaches they were almost all through carelessness on the user’s part (ie. stolen laptop). There were certainly many cases of lost or stolen paper charts in the past as well. It is true that with technology it’s much easier to carry around 1000 patient records and lose them (even on accident). So, that does change the situation.

    Carl makes a good point that paper has its own security issues. In fact, that’s partially why I said that this will be a series. There are lots of sides to using paper or electronic. In the future I’ll be covering more and more of each.

  • “First, in the paper world we often didn’t know when something was breached.” I’ve got news for you. In the HIT world, you still don’t.

    The TRICARE data breach this fall alone exposed 4.9 million financial and medical identities. Seriously, John. You can’t really believe that the current epidemic level of data breaches existed with paper records.

    As far as attributing the data breaches to carelessness, I’d point out that authorities suspect that the health records stolen in the TRICARE breach were targeted. (See: Howard Anderson’s “TRICARE Breach Victims Report Fraud – 8 Class Action Lawsuits Pending; Consolidation Sought”)
    http://www.healthcareinfosecurity.com/articles.php?art_id=4590&rf=2012-03-16-eh&elq=e1ccf903adca416a8399afa26cea1d23&elqCampaignId=1585

    After all, the Ponemon Institute estimates the street value of medical identities at $50 each, and they aren’t targeting paper.

  • I do think the number of breaches was probably similar in the paper world. Just each incident was of much smaller scale.

    I love how they’ve put the value at $50. I’d like to see where people’d pay my $50 for my record. Have you seen where they’ve valued individual records? I can see the medical data in aggregate reaching $50, but not individually.

  • I should add that individually it’s just hard to sale them. If you find the right buyer, it might be worth a lot more than $50, but finding the right buyer for that particular record is hard.

  • John, it’s absurd to compare the numbers of paper data breaches with slippery EHRs. As I said, identity thefts from paper health records was never an issue before EHRs.

    Others who know much more about data breaches than me, such as the Ponemon Institute, would say you are wrong by a long shot.

  • Even the TRICARE breach that you mention I wouldn’t classify as a healthcare breach, but a financial breach. From that report they cared about the financial data, not the healthcare data.

    I’ll be interested to watch the market for illegally collected healthcare data. There is a market for the financial data, but I haven’t seen the same market for health data.

  • Actually, quite a few articles concerning the dangers of medical identity theft have appeared on the internet, including one from the FTC:

    “Medical Identity Theft – Could identity thieves be using your personal and health insurance information to get medical treatment, prescription drugs or surgery? Could dishonest people working in a medical setting be using your information to submit false bills to insurance companies? Medical identity theft is a twist on traditional identity theft, which happens when someone steals your personal information. Like traditional identity theft, medical ID theft can affect your finances; but it also can take a toll on your health.”
    http://www.ftc.gov/bcp/edu/pubs/consumer/idtheft/idt10.shtm

    In October, Pamela Lewis Dolan, writing for the Amadnews.com, posted “Medical identity theft a growing problem“:

    “One-third of health care organizations, including physician practices, insurers and pharmacies, have reported catching a patient using the identity of someone else to obtain services, according to a report from the professional services firm PwC.”
    http://www.ama-assn.org/amednews/2011/10/17/bisa1017.htm

    It’s real and it’s getting worse. Not better.

  • John,

    This is a great post!

    In the current healthcare environment where converting from paper-based to electronic charting is mandated, we tend to forget that paper and pen remain extremely sophisticated and versatile cognitive tools. Their designs have been progressively refined and improved over centuries of use and experimentation. By comparison, digital documentation and information display is still in its infancy.

    Off the top of my head, I would add some other benefits of paper charting:

    — Differences in handwriting between individuals immediately indicate who contributed what to the record.

    — Different line width, color, and other characteristics of the marks made on paper can indicate emphasis, authorship, appended data, or other information not conveyed by the text itself.

    — Different colors and textures of paper can indicate different components of the paper chart.

    — The design of the chart binder constrains the order in which new documents are appended to the existing ones, so that the physical order of the pages serves as an intuitive metaphor for the chronological order of health events.

    It is also interesting to think about which advantages of paper carry over and which are lost when paper documents are scanned into an electronic record.

    Rick Weinhaus, MD

  • Great points, Rick.

    I would add that even the wear of the exterior of a patient’s chart subtly brings to the doctor’s attention how long the person has been in the practice.

  • Kellus,
    Yes, and its thickness also gives you some idea of the duration and severity of a patient’s health issues.
    Rick

  • Here’s a paper-related issue that drives me nuts. While government is essentially mandating the adoption of “paperless” EMRs, our government payers refuse to accept digitally signed consent forms for services such as birth control. This means we still need to collect the pieces of paper from the patients and we can then scan them into EMR if we want to for our own benefit – but we must still provide the hard copy for auditors that visit us each year. Glad I haven’t invested in a signature pad company yet… Think about it, we still have to maintain files of these forms!

  • John,
    A great post!
    I translated it into Chinese shortly and posted on Xinlang Weibo, a social media website which is similar to Twitter,leading to heated discussions.

  • Steven Chao,
    Thanks for doing that. Do you have a link to where you posted it on Xinlang Weibo? I’d like to share it with a chinese colleage of mine.

    Also, I’d love to connect. I’ll send you an email, since I’m just getting ready to launch a new site that might really interest you: http://www.emrandehrasia.com/

  • There’s no doubt that for one patient, in one office, paper is the absolute leader over EMRs in terms of ease of use. When considering multiple patients in multiple locations, the potential advantage of the EMR is easily seen.

    The challenge is to transfer the benefits of paper to the EMR. That challenge has gone largely unmet, and it is the primary reason why uptake of EMRs among physicians has been so poor.

    Medicine is a very personal undertaking. Physicians treat patients one at a time, and that’s how patients want it. That treatment is detailed, can be very personalized/customized, and documentation of that treatment varies to meet those individualized demands. EMRs, in their current state, are not user friendly to that type of documentation. While the government, insurers and hospitals are interested in aggregate data, physicians are not – at least not in the exam room, where their documentation occurs.

    For an ever-shrinking number of physicians, typing is a problem. The problem is self-resolving over time.

    For every physician, the “hunt and peck” mode of documentation is a problem. There are many variants – check boxes, radio boxes, drop down lists, “type ahead” automatic completion, etc – but there are hundreds, if not thousands, of locations in any EMR where the physician is required to choose among multiple options in a list. And there is no efficient way to do it. In a paper chart, the required entry simply flows from the tip of the pen. In an EMR, the physician’s attention must shift to the appropriate entry field, the mode of selection must be determined, the proper entry must be found and selected and, often, it must be confirmed, by clicking, by tabbing to the next field, etc. It takes a few seconds longer than simply writing the word and, when multiplied by the dozens or hundreds of times it must be done in a single patient encounter, the time lost becomes significant. Despite this limitation, it isn’t the method of data entry which is the primary problem.

    The issue is how much data is required. Because hospitals and physicians are forced to accept fixed payments from the government and insurers, the natural evolution of EMRs as patient care tools has been altered. Rather than innovating to meet the needs of doctors and patients in the exam room, EMR vendors were forced to focus on the billing aspects of the EMR in order to justify their fees in a fixed-price economy. Therefore, EMRs are designed to elicit the information needed to justify the highest allowable payment rate from any given patient encounter. This is good for office and hospital economics, but is actually counterproductive to patient care.

    For a given patient problem, the EMR doesn’t change the physician’s diagnosis and treatment decisions, but it does slow down the visit process by asking, typically, for more information than the physician needs for those decisions in order to get the required billing justification info needed to maximize the “billing code” for the patient encounter. This process is not only counterproductive to efficient care, but also increases the cost of medicine overall.

    This problem is not inherent to the difference between paper and EMRs; rather, it is the result of the development of EMRs in a government-constrained environment. But it matters, because it is the basis of the very real fact that most physicians would prefer to use paper over an EMR. Until EMR vendors are able to innovate with the goal of improving the documentation needs of patients and their physicians, rather than government and insurers, paper will remain the medium of choice in the exam room.

  • A Davis,
    Great post. I think I’m going to republish it to one of my other blogs so more people get a chance to read it. Obviously the goal of the above post is not to try and encourage the use of paper, but to encourage EHR vendors to consider ways they can get technology to keep some of the same benefits of paper.

    Hi Tim,
    This blog is definitely open to anyone to comment. I’m not sure where your other comment went. I’ve searched through all the comments and only found your previous comment back in may of last year. Looks like the comment you mention didn’t get saved to the database for some reason. I even checked the spam folder in case you had too many links or something that would have gotten it flagged for spam, but didn’t find it there either.

    Thanks for the links back from your blog. You make some interesting points about SOAP. I actually considered the idea of the SOAP format when I was creating the above post. In some ways, a doctor can’t just use paper right away either if they don’t know the SOAP format. So, in some ways they still have to be trained on paper too. Although even then it’s generally integrated with their residency experience so they are trained.

    Thanks for your insights and glad to have you participating on the site.

  • I don’t think the recently discovered Flame malware will ever penetrate metal filing cabinets.

  • Nope, just any passer by that wants to look in the filing cabinet unaudited. There are pros and cons to both paper and electronic.

  • Like the exaggerated danger of paper-based breaches and paper cuts, your concern that passers-by have the interest or opportunity to snoop through dental records stored in noisy metal filing cabinets looks to me like a weak attempt to distract attention from the tremendous security vulnerability of EHRs – which unlike paper records, are being fumbled in epidemic levels, John.

  • If EHRs are stolen, passers-by can not only look through them “unaudited,” but any changes made by a medical identity thief will be undetectable. Can’t do that with paper.

  • Actually there are more and more stories coming out all the time of staff looking at records they shouldn’t look at. I think this is more of a danger than some random bot computer in Malysia breaching a medical record. One has specific intent, the other is unlikely to do anything with the record.

    EHR’s aren’t stolen. Possibly some of the data in the EHR is exposed. The bigger concern is lost/stolen devices that are unencrypted. This is the most common breach, but has very little to do with EHR. There are very few breaches that have to do with EHR. Most of the breaches I’ve seen are misuse of technology with no relation to EHR.

    We’ve had this conversation before though. I’m sure we’ll never see eye to eye on it. EHR is the future of healthcare documentation. So I find it more valuable to look at ways to make it more secure vs trying to encourage paper use which has its own flaws.

  • I agree, John. That’s why I think electronic dental records should be completely de-identified.

    PHI exposure can be tightly controlled if it’s only available to those who need to see it to do their job.

    By the way, from a consumer’s perspective, it is very hard to separate data breaches of their PHI from the EHRs where they originate. Regardless, it will be the doctor who suffers the consequences. Not the EHR vendor.

  • I wouldn’t be so quick to discount the impact of Flame. It sounds nasty. From what I’ve heard, virtually anyone can use it to collect whatever information they are interested in. It’s like a hacker’s dream tool.

    Good thing nobody is interested in dental treatment histories.

  • That final point is key to me. Dental and medical histories are so much harder to extract value compared to financial data. Flame and other hacks/viruses/worms/trojans/etc will be all about financial data (which is also stored by many healthcare providers). Most won’t give a second thought to healthcare data.

  • Actually, Flame can even record screen views and keystrokes. It’s got everything anyone could want.

    As to your point that hackers are more interested in financial identities than medical identities isn’t reflected in their black market prices. Stolen medical identities fetch $50, while social security numbers and birthdates only bring $5.

    Stolen dental identities on the other hand, are worthless.

  • I read the report that valued a medical record at $50. Take a medical record and try to find a place to go and sell it. It’s a difficult (if possible task). It’s easy with financial data. Something is only worth what someone else will pay for it. Plus, if we’re talking medical identity theft, that still goes back to the financial side of things.

    We should be careful for all of these things of course. I think we should do better at securing healthcare data. I just think people overstate the value of healthcare data from a breach.

  • Even though I don’t personally know of anyone in the market for the stolen identity of an insured person, according to physicians interviewed by the Ponemon Institute and other researchers, medical identity theft is becoming increasingly popular as more and more people lose their own insurance coverage.

    Healthcare data is probably more valuable than most people think.

  • Imagine the profits from selling $50 medical identities by the thousands, almost risk-free.

    I would assume that organized crime already in business using both hackers and dishonest healthcare employees.

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