Last Exit Before the Paperless Office? I’m Taking It.

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By Richard P. Mills, MD, MPH, Chief Medical Editor, EyeNet

It’s nice that modern highways provide drivers ample notice that a toll bridge is coming up so they can take the “last exit before toll” to count coins (there must be some here in the little tray or center console) or visit an ATM before venturing into the zone where there is no turning back. Roadside proprietors find that marketing signs declaring “no food or gas for the next 87 miles” are good for business. Parking lots install helpful yellow lights that flash when you are over height and about to have the top of your RV sheared off. But there are no signs warning you when your practice is about to go paperless, probably because, to date, nobody has actually accomplished that feat in a medical office. Paperlessness is a major theoretical advantage of the electronic health record (EHR), but most offices find there is an increase in paper upon implementation of the EHR. Requests for records used to generate several pages, but with EHR, you need a shipping envelope and mega-extra postage. But there is no doubt we are headed headlong toward the paperless office. So I am vigilant, ready to take that last exit, before it happens to me.

First, I have a confession: I have a disheveled desk. Actually three of them, one at the office and two at home. Neatniks might call them messy, but they are far from the disorganization of a teenager’s room. They have no laundry or food wrappers on them, they do not have the vague aroma of decay, and I mostly know where the important things are (though that has become less consistent as I age). I think it was back in high school that I strayed from the neatnik path. I discovered if a task was not in clear view on a flat surface, I would forget it needed to be done. Making a to-do list (a favorite strategy recommended by neatniks) seemed always to be one of the items on my to-do list. All went well until the personal computer came along. It’s impossible to do anything with computers unless you are willing to submit to a hierarchical filing system. I developed an uneasy truce under which I could keep my piles of things on the desk to be worked on, and I put the completed stuff on the computer in its files.

The EHR works that way, too. The patient represents a somewhat disheveled piece of work to be done (often in a delightful human package), and the EHR records the completed work on that patient. Here comes the pernicious part. Neither the patient nor the computer has any paper intrinsically associated with them, so the ongoing process of medical care fuels the dream of a paperless office. The neatniks will be triumphant. They think of sharing an EHR among all the patient’s caregivers without lab slips or x-ray films, writing orders and having them carried out, tracking clinical guidelines, and automatic fulfilling of payor requirements. To a non-neatnik like me, it sounds ghastly. The neatnik apparatchiks will come to clean off my desk(s), burn my prescription pads, confiscate my Post-it notes, and force me to consult my computer or smartphone to discover if I need to pick up milk on my way home.

Fortunately, we are in a prolonged transition period, during which the cluttered desk can still thrive. Patients have temporary paper charts that follow them as they travel within the office so the staff can keep track of who has done what and who is next in line. But I always keep an eye open for that last exit that someday I may need to take.