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Fall 2024 Issue

Documentation Dilemmas: The State of Paper in Health Care: An Analysis
By Susan Chapman, MA, MFA, PGYT
For The Record
Vol. 36 No. 4 P. 6

In the digital age, the persistence of paper documentation in health care remains a perplexing and significant issue. Despite advances in technology and the push for EMRs, many health care providers continue to rely heavily on paper documents.

Ryan Fair, Extract Systems’ Regional business development manager, along with Rob Fea, the company’s vice president of professional services, presented on this topic at the Ohio Health Information Management Association meeting in spring 2024. Their discussion1 offered insights into some of the reasons behind the enduring presence of paper in health care, the types of documents still on paper, the state of interoperability, and the solutions to move toward a more digitized future.

The Persistence of Paper Documentation
Even with the increasing adoption of EMRs, a substantial amount of health care information is still managed on paper. Nationwide, some 16.3B pages of paper are being processed to the EMR. That figure reflects about 3.1 billion each year that is processed within HIM, and the approximately 13.2 billion pages that are processed outside HIM.1

Although many health care facilities have EMRs, many institutions also maintain paper records. This is especially true for older documentation, which predates an organization’s adoption of a digital system. Smaller laboratories, in particular, continue to provide test results on paper and, within the industry, paper referrals, often generated by primary care physicians and specialists, predominate. Additionally, many health care providers issue paper bills, and release of information requests for health information, including medical records, are often sent and processed via paper. The latter is quite often the case when organizations are responding to insurance and legal requests.

Security is one of the primary motivators for organizations to continue utilizing paper documentation. “Most hospitals consider their patient data theirs,” Fair explains. “Different hospitals want to keep their information and maintain its security. Anytime you send patient information, there is a chance of that data being intercepted. So, the methods used in the past, such as fax, are still considered the most secure way of sending information.”

Paper documents can be sent via courier services, which is an especially common practice in rural or remote areas. At other times, organizations will email documents that are then printed for placement in files or further processing. Printing and scanning are standard operating procedures in many facilities as is the widespread use of fax machines because of their security and reliability.
It is estimated that 90% of health care organizations transmit some 75% of their documents using fax machines.1 “This is because fax machines aren’t hackable in the same way digital information is,” Ryan says.

State of Interoperability
The HITECH Act incentivizes improvements in privacy, security, and meaningful use of EMRs. In 2018, CMS renamed its Meaningful Use program to Promoting Operability, the goal of which was to improve the submission, collection, and patient access to health information.2 In health care, operability, also known as interoperability, refers to the ability of different information systems, devices, and applications to access, exchange, integrate, and cooperatively use data in a coordinated manner.

Although the health care sector faces challenges to improve interoperability, according to data from HealthIT.gov, there has been notable progress in making electronic health information available and usable across different health care settings. In terms of hospitals’ ability to gather health information from external sources, comparing 2017 with 2021 figures, hospitals across the board realized an increase from 51% to 62%. Suburban and urban hospitals saw a 10% rise, and small, medium, large, and rural facilities saw similar upticks.1

From 2017 to 2021, electronic health information received from external sources experienced even larger gains, with all hospitals realizing an increase of more than 15%, with suburban, urban, medium, and large facilities seeing gains of 12% to 14%. Rural and small hospitals saw the largest improvements of nearly 20%.1

Barriers to Interoperability
Despite these advances, several barriers still hinder full interoperability. Lack of standardized measures often complicate data sharing, and inconsistent standards across different systems can prevent a seamless exchange of information. There are also issues with patient-identification systems, which can lead to patient mismatches. And, as Ryan observes, some organizations are resistant to share data because of privacy or other concerns. Additionally, while rural and smaller hospitals have experienced improvements in interoperability, they remain heavily reliant on paper documentation, a challenge Ryan believes stems from the high costs involved in implementing interoperable systems. “Rural and smaller organizations tend to have fewer resources than their larger counterparts, like well-funded university research hospitals,” he says. “In the industry, we often see economies of scale with automation, but in smaller or rural organizations, there simply isn’t enough volume to make up for the startup costs for interface solutions. For them, it remains practical to keep doing things manually.”

Some Potential Solutions
Given the challenges with interoperability, noninterfaced solutions are often employed to manage paper documentation. One of these is manual in-house processing, which has low technical requirements and somewhat predictable costs. Some of the challenges of this method, though, are obstacles to ensure compliance, accuracy, and timeliness, and cost increases as volumes expand. If organizations choose to outsource their processing, they can realize lower labor costs and access a larger pool of talent, but they risk damaging employee morale. Moreover, they relinquish control over the data, which can result in decreased security. They can also encounter difficulties when trying to ensure timeliness, compliance, and accuracy.

Optical character recognition technologies offer an automated approach to handling paper documents by converting them into machine-readable text. These advances can have a lower cost than other methods and increase accuracy, timeliness, and compliance. They also allow a health care system to maintain control of its information.

Achieving complete interoperability remains the ideal solution for managing health information because of the accuracy and timeliness of the information it can offer. However, reaching this level can require overcoming significant technical, financial, and organizational barriers.

The Future of Paper-Based Documentation
At its core, health information is personal, reflecting the patient’s history, and HIM professionals play a crucial role in maintaining the human aspect of their information. “Health information is not just data; it represents the stories and lives of patients. Ensuring this information stays human and relevant is crucial for the future of health care. As we navigate the complexities of transitioning from paper to digital, the role of HIM professionals and advanced technologies will be paramount in achieving a more efficient and connected health care system,” Fair acknowledges.

However, he believes the perception that paper-based systems afford real levels of protection is erroneous, especially when compared with cost. “Paper-based systems are going to protect you when things like ransomware attacks occur, but the downfalls of a paper-based system are just too much to make them worth it unless we’re talking about the smallest of practices,” he says. “And even then, you see these very small community practices starting to move to some of the smaller EMR solutions. Even though a paper-based system can protect an organization to some extent in more extreme situations, I think it makes much more sense to digitize all of your patient information and set up a great security system to protect this information.”

“It’s very hard to predict the future,” he adds. “As the world becomes more digital, health care will follow suit and move away from paper documentation. But this doesn’t mean that patient information will be easily accessible between hospitals and health systems. I think there will continue to be challenges, like that of different EMR systems talking to each other. There will always be a place for solutions connecting data.”

— Susan Chapman, MA, MFA, PGYT, is a Los Angeles–based freelance writer and editor.

 

References
1. Fea R, Fair R. State of paper in healthcare. [PowerPoint Slides]. Extract Systems. Published 2024.

2. Alder S. What is the Hitech Act? 2024 update. The HIPAA Journal website. https://www.hipaajournal.com/what-is-the-hitech-act/. Published January 11, 2024.