Paper Is Contagious

In case you missed the previous article by Stephan Herron from Scriptel Corporation, he’s what inspired the title for this article:

Paper Is Contagious

I was just totally struck by this simple comment because it’s so completely true.  We saw this at the height of COVID when many healthcare organizations printed out a piece of paper with their cell phone number and taped it to their front door with instructions to text or call them to check in.  When a patient arrived they would text or call the office and the office would reply when it was time for them to come in.  A very low tech solution to the problem.  Paper is powerful, but why?

A decade or so ago, I wrote an article (which I can’t find right now) which described the perfect EHR.  This EHR was infinitely scalable.  The templates worked for any doctor and adapted to however they wanted to document the visit.  There was almost no training needed to use it.  Everyone knows how to use it from day 1.   I could go on, but I think you get the point.  It sounds like a great EHR, no?  Of course, I’m really just describing paper.

In my mind, this is what makes paper so contagious.  Paper is a genius invention that has so many good characteristics.  In fact, it’s best characteristic is how flexible and adaptable it is to any situation.  It really is a challenge to compete with that flexibility.  Yes, that ignores the downsides of paper (illegible handwriting, decomposes or gets destroyed by coffee, has to be stored, can be hard to find the paper you wrote on, etc etc etc) but those can all be dealt with if what you’re really looking for is flexibility.  Let’s be honest, it’s hard to replicate the features of paper.  That’s why it’s “contagious.”

We see this actually happen a lot in healthcare.  A great example of this is the fax machine.  I know that a lot of people really want to get rid of the fax in healthcare.  So much so that they started the hashtag #AxtheFax.  While I’m not here to defend the fax (even if digital fax solves most people’s complaints), there’s a reason why faxes are so pervasive in healthcare today.  The fax has two big features that are hard to replicate in a replacement.

These are the two things that make fax special: every healthcare organization has a fax number and everyone can find your fax number even if they don’t know you.  If you can replicate those two things, healthcare organizations would be happy to leave their fax behind.  Of course, the problem is that these two things are really hard to replicate.  This is why fax has had such a long life in healthcare.  The same principle applies to pagers.  Excel is an amazing competitor for so many analytics offerings and is another example.

While there are exceptions to this, I’ve found that many of the “old technologies” are still being used in healthcare are there for good reason.  Sure, sometimes organizations just don’t want to change.  However, often these old technologies have features that are hard to replicate in the latest technology.  Figure out how to replicate those features and you’ll find replacement much easier.  It’s why paper is so “contagious” and why a true paper-less office is far away.

About the author

John Lynn

John Lynn is the Founder of 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.

2 Comments

  • Almost universally, doctors hate EHRs. They like the idea of the promised advantages, but hate the actual use of EMRs and HISs to populate such an EHR.
    Paper is one end of the spectrum, and a 30 minute fight with codes for Diagnoses, Medicines, and Treatment Plans is the other end. It wastes everyone’s time with the exception of those obsessed with Beans or Reimbursements.
    These systems were all designed to “Capture the Requirements”, but they start with the technical, rather than starting with the paper. They start with the beans and not the Doctor.

    What would an Ideal Medical System look like? It would look like a piece of paper to the physician, and beans categorized by size and color to the other analytic end. How could we do that?

    By starting with the paper. Physicians have been trained to handle a patient encounter and the documentation of that encounter in an individual yet disciplined way. They are the expert interface with the patient, and that should be their focus. It would not be much of a stretch to teach physicians to use a keyboard, but they should not be subjected to the rack of a week of training in how to use an EMR. If it is that complicated for them, you are wasting valuable resources.

    Sometimes what you need, after you see a failure as we see in Healthcare IT, is a clean sheet of paper.
    That is exactly what Systems and Clinicians need to correct the problem. A suggested workflow—-
    A physician sits down with a patient with a screen next to him. The screen is a blank piece of paper, or perhaps a form template that the physician has created for himself. At the top is all of the patient information with the time and date of the current encounter, and an arrow for the physician to click to see the last paper document created. There would be tabs at the top of the page for notes, diagnostics, orders, and patient communications.
    If the Clinician hits the arrow it scrolls back to the last document, the last document in a chronology that stretches back as far as the patient’s history with that organization or clinician. All of these documents are images of paper pages, much as if you were thumbing thru a paper chart. The edges of the documents would show, much as a offset stack of pages, color coded much as the tabs at the top. If the clinician clicks on one of the tabs, the document stack presented would include only those category of images of paper documents.
    Going back to the current encounter tab, perhaps the physician has instructed his nurses to put the current patient parameters in free text or in a self-made form at the top. Temperature, Blood Pressure, O2, Weight, etc.
    The physician would then assess the patient, do the H & P, confer with the patient, and then create a free form text block on the paper document on the screen in any way that makes sense to them, putting the new orders at the end. He clicks Done, and the document prints out at the Nurse’s Station where they can implement the orders.

    On the greasy side of the EMR/HIS, a trained Medical Scribe then takes the document that has been queued and performs any encoding or processing necessary to interpret the text of the encounter document.
    That’s the point where designers can go nuts putting in their own version of “The Rack”, realizing that real people will need to work in the environment they have created, and that the Physician is the one who determines what information is available to the system, therefore the scribe should not be held to Mandatory Entries. You want something specific, you will need to talk to the physician about what you want collected in the text, and you will need to justify it to them.

  • Terry,
    Thanks for the comment and a lot to unpack here. I’ll start with your initial comment that doctors almost universally hate EHRs. Do they really? Or do they just hate the documentation part of their job and the explosion of documentation requirements that their job has put on them? Doctors universally hated paper charts too. That’s why stacks of paper charts would be seen on doctors’ desks. They didn’t want to do the paper chart documentation either. They also hated searching for paper charts and hated reading their colleagues (and sometimes their own) terrible handwriting. Don’t hear those complaints in EHR since they just take those for granted.

    Don’t get me wrong. There’s a lot more EHR vendors can do to make EHR software better for doctors, but I think much of the ire around EHR software is a reflection of the reimbursement and regulatory documentation requirements and not the EHR itself.

    I actually disagree that the ideal system would be a piece of paper. A lot of doctors hated paper. They hated that their colleagues wouldn’t document everything that was needed for them. They hated that they didn’t get reimbursed at the higher levels because they didn’t want to document all of the exam that they did. Sure, they loved that they loved the flexibility of paper. It’s probably better described that they loved that no one was controlling how they were documenting. Well, they loved it until they realized that the way they were documenting on paper wouldn’t get them paid by the insurance companies, but that’s a different ire.

    Your description of being able to scroll back through each visit document is great until the doctor wants to graph the lab results for the last year and see how they’ve changed or when they’re searching for a specific note and have to search through hundreds of pages rather than just searching for the keyword and being taken to the note.

    My point here is that it’s much more complex than you’re making it seem. It’s easy now that we’re in the world of EHRs (and not going back) to romanticize how good paper was, but it’s easy to remember the good and forget the bad.

    Of course, your ideas are heading in the right direction. The ideal doctor workflow is that they walk into the exam room, they see the patient, they care for the patient and then when they walk out of the exam room the documentation has been done for them. That’s the ideal doctor workflow. Ambient clinical voice is working towards this workflow. It may take some review by the doctor after the fact, but it’s getting us much closer to removing the documentation burden from the physician. Plus, it satisfies all the regulatory and reimbursement requirements along with the granular data that will be needed for future clinical decision support and other areas like that. The right AI layer could even create different views like the narrative note that doctors would really like to see. Is it there yet? No. Are they making great progress? Yes.

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