Paper in surgery centers is good, actually

It’s rare to see people using paper very much at work in 2024.  Most people are using text messages, apps and web browsers on their smartphones and they enjoy interacting with work in the same way.  We’re all used to the benefits of digital technology so we don’t see business happen on paper very much in the workplace anymore… unless you spend much time in ambulatory surgery centers (ASCs).

If you have a procedure done today at one of the thousands of ASCs in the United States, it’s very common for the medical records of your procedure to exist as a printed paper chart.  Some of the contents of this paper chart are documents that have been faxed over from other healthcare providers (labs, H&Ps, EKGs, surgeon’s orders) and some will be forms and templates that the medical staff work with to deliver care: consents to sign and forms that guide the workflow and record everything that happens during your visit.  It doesn’t take long for an observer to ask…

In 2024, why do ASCs still use paper charts?

If you visit a surgery center in 2024, it’s natural to ask why they still run on paper charts.  It’s clear that the people who work in ASCs all use digital technology in their lives and believe that it is generally useful, yet why do ASCs continue to use paper for medical records so often?

Some say that this is because the federal government’s Centers for Medicare Services (CMS) had provided financial incentives to most types of medicine to transition to EHRs, but exempted ASCs from this process.  As a result, ASCs had never been forced to adopt EHR software for medical records.

While this answer makes sense, it suggests a follow-up question: why do healthcare providers need external financial incentives to adopt electronic medical records?  If most of the world has adopted digital technology in 2024 because it’s better than paper, what makes healthcare different?

EHRs have issues

If you ask doctors what they think of EHR software, be prepared to listen to complaints.  

A study from 2022 highlighted that there is significant correlation between physician burnout and negative attitudes towards EHR software.  In addition to burnout, most respondents indicated that EHR systems negatively contributed to efficiency of care.  A 2020 study of plastic surgeons went so far as to quote a surgeon as saying “EMR is a major reason I am retiring at age 67”.  Most respondents said that the EHR had a negative effect on both workflow and on operating costs.

Some have hypothesized that difficulties with EHR systems are due to a generational divide, where younger physicians are happier with EHR systems than older physicians.  However, many studies have not found support for this and have found either no significant difference in attitudes between young and old surgeons, or have found little association.  These results indicate that the problems with EHR systems aren’t slowly going away as their detractors choose to retire.

If electronic charting slows down the workflow in a surgery center, what’s the true cost?  A 2017 study estimated that every lost minute in an OR costs about $36.  Given how precious every minute in a surgery center is, It’s not hard to see why many ASCs haven’t deployed EHRs yet.

What’s wrong with paper?

So, if providers believe that electronic charting is going to slow down the surgery center, why not just stick with paper charts?  Well, paper charts have problems too.

Paper charts are time consuming to create and store.  ASCs generally have multiple employees devoted entirely to the creation and storage of patient medical charts.  Additionally, regulations require ASCs to maintain copies of medical records for years, which can mean managing large physical cabinets of charts while paying rent on the office space that they occupy.

In addition to the time and money that goes into maintaining paper charts, the information that is inside them is hard to get at.  While paper gives your clinical staff a quick and easy way to record data, that data is hard to get back out without someone spending time pulling charts and searching for it.  And if you’d like to analyze large amounts of medical record information, it can involve large amounts of work.

Do we have to make tradeoffs?

If paper charts make it easier to perform many clinical tasks, while electronic charts make it easier to perform a lot of administrative tasks, is it possible to build a medical record solution that combines the best of both?  Can we build a system with the following characteristics?

• Administrative staff can work almost entirely with electronic medical records for a highly efficient administrative workflow
• Clinical staff can work almost entirely with paper medical records for a highly efficient medical workflow
• Paper chart creation can be mostly automated and require a minimum of manual labor
• The information from paper charts can be easily accessed and analyzed via electronic systems instead of sitting ignored inside filing cabinets

How does modern technology finally allow this to exist?

While we’ve had the ability to scan paper charts for a long time, it wasn’t until the advent of modern AI technology that computers could really understand the contents of scanned, possibly handwritten documents.  This powerful technology can be applied in many ways in an ASC:

• Paper charts can be automatically audited for missing pages, missing signatures or missing times, instead of needing a human to do this review.
• Faxed documents can be understood and automatically filed for administrative staff.  AI systems can be used to automatically determine the type of document being received and to connect it with the correct patient record.
• Useful information can be extracted from scanned patient charts.  Instead of humans keeping painstaking records of procedure times, fall logs, and inventory usage, this information can be extracted automatically from patient charts and aggregated into useful reporting. 

We now have the technology to build a medical record solution for surgery centers that allows the clinical staff to work with the efficiency of paper, while all administrative functions happen with the speed and availability of electronic records.  At InPractice, this is what we are building: a medical record solution for ASCs that is so good that CMS doesn’t have to bribe them to use it.