Operations: Paperless? Not Quite

December 15, 2008

Physicians Practice takes on the holy grail of the paperless office. If you are on a quest for an EMR, take a look at how other practices are building efficiency with a practical mix of paper and digital chips.


You’ve read the articles, you’ve talked to a half-dozen EMR vendors, and now you’re ready to move your practice into the future. Everyone is doing it, and so should you. It’s time for your practice to go completely paperless.

But before you throw out all your patient charts, maybe you should stop and ask yourself: Is it possible to rid yourself of all your practice’s paper? Is going completely paperless even the wisest thing to do?

“What’s the matter with paper?” asks Physicians Practice’s own Pamela Moore. “If you could run an office efficiently and lucratively using clamshells or chocolate bars, I don’t care.”

But don’t start asking your patients to pay you in candy just yet. Sit down and evaluate your practice’s goals: Where do you want your practice to go, and how is paper holding you back?

Needle in a haystack

The real problem with paper is that it takes up a lot of room and is never where you want it when you want it. It’s hardly surprising that you can’t find the one file you need in a room that houses more than 1,000 square feet of patient charts. All it takes is one busy employee to misfile a chart, and then, poof; it’s as if that file never existed.

So it follows that since the general purpose of an EMR is to transfer your paper medical charts into an electronic format, most practices think going paperless will solve all of their problems.

There’s no doubt that the ease of accessing thousands of charts at the touch of a button can have a tremendous impact on your practice’s productivity. An EMR puts an end not only to searching for misfiled charts, but also to marching from front desk to file room, walking back again to use the photocopy machine, and shuffling files between physician offices and the front desk - not to mention the enormous amount of time spent refiling charts that are pulled throughout the day.

“The biggest waste of human resources that people have in their offices is filing,” says John Bonini, a practice manager who has overseen EMR conversions at two orthopedic practices. At Nassau Orthopedic Surgeons on Long Island, Bonini employed 14 front-desk staffers before the office converted to an EMR in 2000. Six months later, that number was down to nine - a 36 percent reduction. Bonini realized that the practice had been paying the equivalent of three full-time employees just to look for and move around paper charts.

“Nobody’s job is called ‘Go look for things all day,’” says Bonini. “But if you add up the number of people who you have doing that all day long in a paper system, that’s about what you’ve got.”

An EMR can free your employees from those types of demands, but what about all the other pieces of paper in your practice? What about the paper that never gets filed in a chart at all - or the paper that needs to be filed, but its still waiting around?

Most experts recommend focusing on your practice’s work flow rather than just dumping all your office’s paper when you go electronic. Paper isn’t necessarily the enemy; waste is. “Your objective is not to get rid of paper, but to make your work flow at your practice more efficient so that you can get a return on that technology investment,” says Moore.

Viewed from that angle, digitizing patient charts is just one component of enhancing your office’s efficiency. Moore recommends that practices map out their entire work flow - literally. She’s helped practices do just that on index cards. Start with patient check in: Where does the patient go, and which employees help that patient? What are the next steps?

“Understand what needs to happen, then you can look at how technology can help you make that better,” says Moore.

Uncharted territory

If you engage in the exercise Moore recommends, you’ll quickly find that most of the paper your office regularly handles isn’t even contained in patient charts.


Consider all the different ways information arrives at your practice. Most outsourced ancillary service reports come in via fax. That includes lab results and consulting reports, not to mention EOBs and the vast amount of communication you regularly receive from insurers. In time, all those things may end up in patient charts, but someone still has to carry those pieces of paper to the appropriate charts and file them. If your charts are electronic, you’ll have to figure out how to get those pieces of paper into digital form - and who will do it.

It’s not as difficult as it sounds, but it does take some planning. Simply implementing an EMR doesn’t guarantee that your practice is ready to use it. You need to ensure that your EMR has a compatible scanning module that allows you to scan documents directly into patient charts in a way that allows you to easily index them. If physicians have to search through 60 pages of scanned documents to find the one they need, they’re wasting their time. The point of digitizing patient records is to make your practice more efficient - not less.

Most practices will also want a scanning module that allows them to route newly scanned documents, such as test results, to the appropriate nurse or physician for approval or follow-up. After all, what good is digitizing a piece of paper if no one ever sees it? In fact, this is one area in which your EMR definitely has it over paper: patient safety.

“When we get results that need to be followed up on, we can track that electronically far easier than we could on paper,” says Rosemarie Nelson, an MGMA healthcare consulting principal based in Syracuse, N.Y. Nelson notes that an electronic tickler function in EMRs can be especially useful for internal medicine, primary care, and OB/GYN practices, where lab results frequently require review.

But there’s still the question of how paper makes the transition into your EMR. First, consider adding a compatible fax server to your EMR. It will digitize incoming faxes, freeing your staff from printing and rescanning paper faxes, which can be an incredible waste of time. Someone will still have to file those faxes in the appropriate electronic chart (or route them to the appropriate nurse or physician), but that’s much easier and less time-consuming than filing paper in a physical chart.

Some lab and consultant reports will most likely continue to arrive via snail mail, so someone will need to scan those items as well. Azim Shaikh, practice manager for Springfield Cardiology, a three-physician practice in Springfield, Ohio, recommends designating only one or two people to scan paper documents into the EMR. Springfield Cardiology’s check-out person scans in all incoming mail, and Shaikh estimates that person spends about two-and-a-half hours each day scanning and electronically filing documents.

But be sure to ask your EMR vendor how its scanning module works. EMR systems index scanned documents differently. “All vendors do not create scanning the same way,” warns Nelson.

A prescription for success

One area in which going paperless can help improve your practice’s efficiency is in e-prescribing. “Twenty-five percent of calls from patients asking for a refill on a prescription happen within one week of their last visit,” notes Moore.

Why? Usually because there was no electronic system that reminded the physician to renew the prescription during the patient visit. An e-prescribing tool can eliminate those follow-up calls as well as the inevitable telephone requests for cheaper prescriptions. A good e-prescribing tool will have some of the formularies from the major payers in your area and can prompt you for less expensive options.

With a good e-prescribing tool, you should be able to send prescriptions to patients’ pharmacies with just a few mouse clicks. Although some pharmacies still don’t accept e-prescriptions, most will be able to accept your electronic signal and print out prescriptions as faxes. Whatever the case, e-prescription also eliminates another big reason for frequent practice calls: illegible physician handwriting.

Often it’s physicians themselves who put up the most resistance to e-prescribing. “Every physician is always going to find that it is faster to write a prescription on a piece of paper than it is to enter it electronically,” admits Nelson.

But that’s generally true only for first-time prescriptions. Nelson suggests that physicians focus on the downstream benefits of automatic prompting and reduced call-back volume.

And remember how often written prescriptions go missing. “All too often, physicians have to leave the exam room and walk out into the hallway to get their prescription pads,” says Moore. “They leave them in the other exam room; they leave them at a table somewhere. They just don’t have them on hand, and there is the inefficiency of walking in and out. Then when you hand that patient that piece of paper, they end up losing it and have to call back in to get another version written.”

Money in the bank

Many times when a practice says it is paperless, it’s really only referring to the front office. All of the patient records are in the EMR, and incoming lab reports are scanned twice a day, but there’s still an entire department that combs through paper reports and shuffles paper files. If the front office can benefit from paperless efficiencies, then what about your billing department?


Although most practices send out electronic claims, very few take advantage of electronic remittance. The vast majority of practices are still receiving printed checks that must be physically carried from the office to the bank for deposit. The problem is that a trip to the bank might not happen for two or three days - or sometimes not at all.

“We have talked to many offices where some staff member quits and the next person to come in opens a drawer and finds all these checks, thousands of dollars of checks that never got deposited because that person never had time to get to the bank,” says Moore.

Although not all electronic clearinghouses offer electronic remittance, many do. Medicare offers electronic remittance for its claims, yet only 12 percent of practices take advantage of it. Why have your employees waste time driving to the bank and standing in line when Medicare or your clearinghouse can do the work for them?

It’s an efficiency solution that Springfield Cardiology adopted right away. “We receive some paper EOBs from the smaller companies, but everything is done through electronic remittance and direct deposit. So we are really limiting the amount of paper on that side,” says Shaikh. They are also saving themselves a lot of time.

Moore also recommends that billing departments scan any print EOBs they receive into the EMR. “It’s one of those documents that always go missing,” she says. Just as with patient charts, there is no sense in having employees waste time searching for a paper EOB when a digitized version can be accessed easily by everyone.”

Rome wasn’t built in a day

Although all of these are good suggestions that can increase your practice’s efficiency, don’t expect to implement any or all of them today and go paperless by tomorrow.

“We are certainly not 100 percent paperless at this stage,” says Shaikh, whose practice has been live with an EMR for about six months. “I would say we have eliminated 50 to 75 percent of the paper we were using before we implemented our EMR.”

In fact, the practice increased the amount of paper it was generating when it first switched to its EMR. “We didn’t have our fax server set up right, so we were printing letters and scanning them back in,” explains Shaikh. “We tried to plan the work flow as best we could, but until you go live… ”

Initial wariness was a contributing factor. Shaikh admits that physicians and staffers at his practice weren’t completely confident about their new system when it was implemented. “When we first started the project, we always generated some kind of paper because we wanted to have some redundancy,” he says. Once they felt sure of themselves and the new EMR, they shredded that temporary paper.

Your practice can also expect to keep paper charts for a while after implementing an EMR. Although smaller practices might be able to scan all of their patient charts, larger and more established practices could find that idea too time- and cost-prohibitive. That was certainly the case at Nassau Orthopedic Surgeons. Bonini knew the nine-physician practice had to come up with a plan for what it was going to do with its almost 4,000 square feet of patient charts before implementing its EMR.

The solution was to scan active patient charts. Staff pulled charts for all patients that each physician would see within the next two months and then scanned those immediately. “When the doctor went live on his first day with the EMR, he had no crutch and was totally paperless,” says Bonini.

Then when return patients called to book appointments, their charts were pulled and scanned before they showed up at the office. All scanned paper charts were archived, as New York state law requires medical practices to keep patient records for seven years. At the end of each year, the practice shredded expired charts. Of course, that meant shrinking paper records at a slower rate, but by the end of the third year, only half of the office’s paper charts were still there.

The practice was finally able to get rid of itself of paper charts earlier this year. “They’re actually moving their physical therapy facility, which was in another building, into the space that was doing nothing but storing charts,” says Bonini. “They are freeing up $100,000 in rent and moving their facility into where their chart storage used to be. It’s amazing.”

Check your state regulations for retaining medical records. Chances are that your practice is going to have some kind of paper - even if it’s just in storage - for a few years after you implement an EMR. If your practice is small enough or new enough, you could consider scanning all your patient charts, but don’t expect that to be a rapid process either. Springfield Cardiology spent nearly nine months scanning in five years’ worth of charts for its three physicians.

The myth of the paperless panacea

Everyone pretty is much saying the same thing: Forget about paper; think about being more efficient. To that end, you may find certain areas in which paper just can’t be excised from your practice - and that may not be such a bad thing.

Many practices, for example, find it difficult to eliminate patient history summaries on paper. Physicians generally read a chart summary before entering the exam room so they can familiarize themselves with the patient’s history. One practice Moore dealt with had dispensed with that paper summary altogether. “The physician opened the door and literally did not know who was in there,” she says. “Talk about a problem with patient service.”

But how will your practice’s patients react to a physician who goes directly to the exam room’s laptop before starting a conversation?

To avoid problems like these, Springfield Cardiology still prints “doctor data sheets” for its physicians. “As long as it doesn’t slow down the efficiency of the organization, I don’t have a problem with a temporary piece of paper and shredding it afterward,” says Shaikh. A number of EMR-enabled practices also continue to print out their daily schedules.

Even though work flow may be coordinated through the EMR, the staff is accustomed to working from a paper schedule. “If that helps you and helps your work flow, you shouldn’t feel like you can’t print out that schedule because you’re not allowed to have paper,” says Moore. “The main objective is work flow - not getting rid of paper.”

Certain specialties may find it particularly difficult to shed visit documentation. Nelson cites pediatric practices as one example: “Pediatricians have done a very good job of creating paper forms or templates, especially for well-child visits,” she explains. “They pull out the form based on what that patient’s visit is for, and they’ve got something that’s really easy for them to fill out by hand, check off the boxes, and do that quickly.”

Something like that could be incorporated into an EMR, but it doesn’t have to be. If checklists and forms like them work well for your practice, there’s no reason to discontinue them simply because they are paper-based. Just build a step into your practice’s work flow that allows those checklists and forms to be later scanned into patient files. A temporary piece of paper like this one can help your practice work flow more than hinder it.

Taking the leap

But perhaps your practice has heard the above arguments, and it still wants to eliminate all paper. If you really want to make that happen, you can. Look at North Carolina Orthopaedic Clinic in Durham, N.C., where John Bonini orchestrated another EMR conversion. It now has no chart room or any physical space for filing paper of any kind. “I can truly say that there is not a piece of paper that we haven’t gotten rid of,” says Bonini.

And not only did the practice scan all of its patient charts. It also dispensed with its printed chart summaries and daily schedules. A terminal outside the nurses’ station allows physicians to review patient histories before entering exam rooms.

It took a lot of homework for the practice to get to this point, Bonini says. Every step of the office’s digital conversion - from scanning patient records to implementing work flow solutions - was planned far in advance. Although many EMR companies provide a checklist for how to go paperless, Bonini knows those checklists don’t tell practices how to look at work flow, conduct internal meetings, and figure out what to do with paper charts. “EMR companies don’t manage medical practices,” says Bonini. “What do they know about that? They know how to make their software help you, but they don’t know how … to improve your office to accept this solution.”

You should also expect any paperless move to take time. “I think too little time is spent by groups thinking of the EMR as a transition versus a start-stop. Practices should see the EMR as an evolution, which will be more likely to succeed,” says Nelson.

Still, not everyone is able to make that final leap. “There are a lot of people who are just scared. Even though they have come up with the plan, they are scared to throw away that paper,” says Bonini. “If you are scared to jump off a diving board, you’re never going to jump. You’ve got to be able to have the confidence that you have a good plan.”

Robert Anthony, a former associate editor for Physicians Practice, has written for the healthcare and practice management industries for five years. He is based in Baltimore and can be reached via editor@physicianspractice.com.

This article originally appeared in the May 2007 issue of Physicians Practice.