Technology: Paperless? Not Quite.

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 of your patient charts, maybe you should stop and ask yourself: Is it possible to get rid of all your practice’s paper? Is paperless really even that great?

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

Don’t start asking patients to pay with candy just yet. But you can use this opportunity to 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 need it. It’s hardly surprising that you can’t find the one file you need in a room that contains 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 has ceased to exist.

Since EMR systems are focused primarily on getting the medical chart 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 help. 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 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 an EMR conversion 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 amount 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 kinds 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 - or the paper that hasn’t been filed yet?

Most experts recommend focusing on practice work flow instead of just throwing out paper. Paper isn’t necessarily the enemy. Waste is the enemy. “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 better 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 practice deals with isn’t even located in the chart.

Consider all of the different ways information arrives at your practice. Most outsourced ancillary services come into your practice via fax. That includes lab results, and consulting reports, not to mention EOBs and the vast amount of communication from insurers. All those things may end up in the chart eventually, but someone still has to carry those pieces of paper to the chart and file them. If the chart is electronic, you will 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 having an EMR doesn’t guarantee that your practice is ready. You need to make sure that your EMR has a compatible scanning module that allows you to scan documents directly into patient charts in a way that they can be easily indexed. If physicians have to search through 60 pages of scanned documents to find the item they need, then time is wasted. 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 where 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 is still the question of how paper makes the transition into your EMR. First, consider adding a fax server that is compatible with your EMR. A versatile fax server will digitize incoming faxes so that your staff can avoid having to print and rescan 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 most likely will still arrive via mail, so someone will need to scan those items. Azim Shaikh, practice manager for Springfield Cardiology, a three-physician practice in Springfield, Ohio, recommends making only one or two people responsible for scanning documents into the EMR. Springfield Cardiology uses the checkout person to scan in all incoming mail, and Shaikh estimates that person spends about two-and-a-half hours each day on scanning and electronic filing.

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

Prescription for success

One area where paperless can help to 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 a 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 physicians for less expensive options.

With e-prescribing, a physician should be able to send the prescription to the patient’s pharmacy with just a couple of clicks. Although some pharmacies still don’t accept e-prescriptions, most will be able to accept that electronic signal and print the prescription as a fax. Whatever the case, an e-prescription also eliminates another reason for frequent calls to practices: illegible physician handwriting.

Often the primary resistance in the practice to e-prescribing comes from physicians themselves. “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 trying to help physicians focus on the downstream benefits of automatic prompting and reduced call-back volume.

If that doesn’t work, remind physicians of how frequently that prescription goes 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.”

No such troubles with e-prescribing.

Pay attention to billing

Many times when a practice says it is paperless, it really means only 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 need to be physically taken 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 - and 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.

Though 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 in any print EOBs they receive. “It’s one of those documents that always goes 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

All of these are good suggestions to increase your practice’s efficiency, but don’t expect that you can implement any or all of them and go paperless 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 EMR.”

In fact, the practice increased the amount of paper it was generating when it first switched to an 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 little while. Although smaller practices might be able to scan all of their patient charts, larger and more established practices could find that idea 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 it’s 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 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.

When return patients called to book appointments, their charts were pulled and scanned before they showed up at the practice. 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, but that meant shrinking paper records slowly. By the end of the third year, about half of the paper charts were still there.

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

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

Is paperless pointless?

Everyone pretty much says the same thing: Forget about paper, and think about being more efficient. To that end, you may find certain areas where 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 that 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.”

How will your practice’s patients react to a physician who has to go directly to the exam room laptop before having 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 practices also continue to print out the daily schedule. 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. 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 the EMR, but it doesn’t have to be. If checklists and forms like these 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 scanned into the patient file later. A temporary piece of paper like this one can help your practice work flow much more than it hurts.

If you want it badly enough

Maybe paper isn’t so bad after all, but your practice still wants to eliminate it completely. If you really want to make it happen, you can. Look at North Carolina Orthopaedic Clinic in Durham, N.C., where John Bonini has overseen another EMR conversion. It has no chart room and no 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.

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

It took a lot of homework for the practice to get to this point, Bonini says. Every step of the practice’s digital conversion - from scanning patient records to implementing work flow solutions - was planned 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 tell you 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. His work has appeared in Physicians Practice, edge, Humana’s Your Practice, and Publishers Weekly. 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.