Removing Paper

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We shouldn't get rid of paper

It will be a LONG time before paper is eliminated so we need to realize this and stop making things harder on people by refusing to print things. The trick is to make useful reports so endusers will clearly see that ENTERING clinical data will make their reports better. In my opinion, the most import thing is to get good data into the system in a timely manner where it is accessible to all including our clinical decision support applications. Good reports can be a means to this end. Then when really good portable devices are available , the paper reports might go away by themselves.

Another site reports they are taking a gradual, pragmatic approach. When it appears that there is no longer a business case for printing a particular set of documents, they ask the involved business units whether they still see a business case. The people on the units have been uinformly helpful in either letting them know that there is no further business case or telling them what the business case is. They report their success in discontinuing unnecessary printing to senior leadership about quarterly. In all this, we remember that for some work processes printing paper may well be the most cost-effective approach--now and for some time into the future.

Using Paper can increase system acceptance

One site got residents to use the old TDS system in the early 1990's by providing a printed rounding list that mimicked the one they did by hand. After the implementation of Cerner last year, the administrators (who don't use the system, or even practice medicine) decided to eliminate this and other useful reports. The residents now manually type this report that was once automated and print copies for all at sign out time. Result: no paper savings and great loss of time.

Policy and Procedure Considerations

At Cedars-Sinai Medical Center (Los Angeles), they first had to amend their formal Policies and Procedures describing the medical record to change it from "paper" to a combination of electronic and paper records. Conversion of records to electronic form is approved by the medical staff's Health Information (Medical Records) committee and ratified by the Medical Executive Committee. Printing was discontinued for all Pathology Lab and Imaging dept results 5-6 years ago, followed by discontinuation of printing all ICU and Emergency Department records. Electronic medical records and a self-developed Web Viewing System are available locally & remotely for physicians to view records. More recently, all dictations except History and Physical exams were made in electronic format only. There were a few naysayers at each step of the way but these changes have been well received by a 2,000 member medical staff, 85+% of whom are in private practice.

Don't forget the patients...

In 1999 at Bellevue Hospital in NY, NY, they began to implement a 'less-paper' primary care clinic. Outpatient lab orders taught them an important lesson: They built electronic orders for CPOE and created new and improved physician, nurse, and laboratory workflows that leveraged the CPOE system. They quickly discovered, however, that patients wanted a paper reminder to have a lab test. Ultimately, they created an outpatient instruction sheet that included tests ordered, consult appointments, and other follow-up care for the patient. The single page form was not required for completing diagnostic tests (the actual orders were electronic) and required less paper than the original printed test orders. In the end, providers, the lab, the finance department, and the patients appreciated the new processes.

Key Points to Consider

People like to hold onto something so we have taken the "you can still do it" approach, but don't make it easy for them.