In the first years following my practice’s implementation of a comprehensive EMR, hospital I likened our situation to that of an advanced island kingdom without any modern transportation links to the mainland. That is, our system provided state-of-the-art patient information management within our facility but could not communicate beyond our walls. We thus were impatiently waiting for the ideal future state, the paperless medical office.
Ten years later, things have barely improved. We were reminded of that recently by a broken fax machine, which provoked a cascade of events that ultimately led to us reviewing our office’s present state of paper production and handling.
The results shocked us: we discovered that we create 20,000 pieces of paper each month through our printers, incoming fax machine and photocopier. That breaks down to
• 6,500 pages of incoming faxes
• 5,000 pieces from printers attached to clinician workstations
• 5,000 pages from a high-volume front office printer
• 4,500 photocopies
To put these figures in context of care volume, our group of 11 family physicians cares for about 10,000 patients and has some 3,000 office visits per month. While that means that the number of pieces of paper per patient or per visit is low, it still reminds us of how far we are from being a paperless medical office.
Since implementing our EMR we’ve made only two inroads in reducing the amount of paper we produce and handle. First, we receive the vast majority of lab results electronically through an interface built into our system. More recently, our EMR system added a fax server, which we use for most prescriptions and for specialty referrals.
But the remainder of incoming and outgoing information travels by paper. Yes, we digitize everything that comes in using OCR, image scanning or manual entry but we still have to handle the hard copies. And we have no choice but to provide outgoing paper in far too many circumstances.
So how do we get from here to the paperless medical office?
The simple answer is that we need a secure electronic messaging infrastructure for our healthcare system. That’s long overdue and a testimony to failure on the part of the eHealth industry and those who regulate it.
But until that day arrives EMR users have to decide what useful interim actions we can take. And my office’s discoveries provide some insights into the nature and volume of medical office information transactions.
Our fax volume is testimony to the challenge of incoming paper. As time has passed, the entities that want to send us their requests or reports have substituted faxing for both phone calls (particularly true of pharmacies) and hard copies previously sent by courier or post. Fax servers have accelerated the trend, as I explained in my recent post on Fixing our healthcare fax fixation.
Many would suggest that we shouldn’t be receiving faxes onto paper at all, instead substituting a fax server to manage incoming reports. But while that saves the cost of the toner, paper and movement of the incoming fax to a scanner, it presents a new problem: managing the electronic document.
To do that means identifying which patient file the document belongs to, applying OCR to text contents, encrypting it and filing it. If you could get a system that can automate those steps for a page that arrives by fax protocol you’d be in luck.
But that’s asking too much of a low resolution, image-based technology like fax. As a result, incoming faxes tend to become attachments that one must open in a separate window. They also tend to be images rather than text, rendering the contents unsearchable. The result is reduced efficiency and safety of clinicians’ information management tasks. Bad idea.
The quantity of printer output demonstrates how little capacity we have to transmit patient information beyond what we can send by fax server. Diagnostic orders for labs and imaging make up the majority of these printed pages. However, we also have to print treatment orders for rehabilitative services (e.g. physiotherapy), individualized patient handouts, sick notes, copies of chart elements and invoices for certain charges.
Finally, even the number of photocopies has something to teach us. Most of what we copy is general information handouts for patients (e.g. lab or physiotherapy locations), which would be better sent electronically to the patient. Much of the remainder are copies of completed pen-and-ink forms. They remind us that a paperless medical office requires connectivity not just among points of care but also to patients and and their designated third parties.
The tragedy of all this paper production is that it’s unnecessary; it’s just an archaic means to move information between needlessly isolated systems. Is it too much to ask that whatever we can create or capture electronically remains forever digital, finally achieving the promise of the paperless medical office?