Paper Has Healthcare Spoiled

Most importantly, paper records are much more secure than electronic.

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.

“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.

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

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!

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.

I don[‘t think I’d worry about that too much, Jonathan.

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.

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.

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.