The paper chart holdouts

October 17, 2018

Some physicians have resisted electronic health records systems and still rely on paper.

Robert Lending, MD, describes himself as a “computer dinosaur.” The Tucson, Ariz., internist and clinical lipidologist gets cash from bank tellers rather than ATMs. He doesn’t make online purchases or use social media. And he doesn’t use electronic health records.

Lending, 65, calls EHRs “the most dangerous, ridiculous piece of equipment I could ever have conceived of,” adding that his colleagues envy him for the peace of mind and extra time he enjoys from using paper charts.

“You can’t believe how angry they are at computers, at the whole system,” he says.

Lending is far from alone. True, physicians’ use of EHRs has soared in recent years, due in part to the financial incentives the government provided through its Meaningful Use program. According to the most recent data from the Office of the National Coordinator for Health Information Technology, 87 percent of office-based physicians were using some form of EHRs in 2015, up from 24 percent a decade ­earlier.

Still, that leaves a lot of doctors who aren’t using EHRs, despite pressures from the government, payers, and sometimes their own colleagues to do so. Medical Economics spoke with some of them to find out why.

Robert Lending, MD

Since beginning practice in the early 1980s Lending has watched as EHRs have spread throughout the healthcare system.

Now he is among a handful of providers at his large, multispecialty practice who continue to use paper charts. While conceding that EHRs offer some benefits, such as data mining and e-prescribing, for the most part he has not liked what the technology has done to physicians or the profession.

“Most of my colleagues are spending an extra one to two hours per day just doing their records, often at ridiculous times,” he says. “Like they’ll see a patient on Tuesday afternoon and finish the note [for that patient] on the weekend.”
Lending dictates his notes on an iPad during the patient visit, in part because he values the level of detail and accuracy it allows.

“When you’re doing a note four days later it’s hard to remember if it was the second left proximal knuckle or the third left distal knuckle,” he says. “My ability to create a useful, accurate note lessens even a day later.” He e-mails the dictated note in audio format to a medical transcription service.

Lending estimates that the government docks him the equivalent of 2 percent to 3 percent of his Medicare reimbursements for not using EHRs. “But I’m willing to give that money up so I’ll have all my charts done before I leave the office, every script is taken care of, and my desk is clean,” he says. 

Similarly, he misses out on a portion of bonuses the practice receives tied to quality data gleaned from providers’ EHRs. “But that’s another thing I’m willing to give away so that I can just do my thing and be a doctor,” he says.

Lending says that if he were younger and had more years of practice ahead he would probably have gone digital by now because “Who knows, ten years from now it may be illegal even to use paper.” As it is, EHR use now is a requirement for any new provider  joining the practice. But he is determined to hold out.

“Why would I want to take the smooth, efficient machine I have in my office and throw this kind of junk [EHRs] in just to be able to be current?” he says. “If my group forced me, that’s when I would quit.”

Ashesh Patel, MD

For Washington, D.C. internist Ashesh Patel, MD, using paper charts rather than EHRs was more a legacy than a conscious decision. But having started down the paper trail, so to speak, he’s reluctant to turn back.

Patel, 46, began his career in 2000 by partnering with an older physician who didn’t use EHRs. Patel followed his example and continued with paper charts even after his partner retired six years later.

“It was more economically feasible to continue than to convert all those paper charts I inherited into electronic form, especially starting off as a solo practitioner,” he explains.

Since taking over the practice Patel has sometimes considered using EHRs for new patients while continuing on paper with existing patients but has found he likes the simplicity and direct patient contact paper charting affords.

“When I see a patient there’s no computer in front of me so I’m always face to face with that patient,” he says. “I write the note in front of the patient and they like seeing me write what they’re saying and knowing they’re being listened to,” he says.

Patel’s day begins around 7:30 a.m. and most days he’s finished charting by 4 p.m. “So I’m not in the position of many doctors I know who are still charting on their computers for an hour or two after their day is over, which leaves me time to focus on tasks like refills,” he says.

Like Lending, Patel incurs a financial penalty from Medicare for not using EHRs. But since only 20 percent of his patients are on Medicare, it’s a price he’s willing to pay for not spending additional hours completing patient charts.

An unexpected benefit of paper charting, he adds, has been the response of the medical students who rotate through his practice.

“I’m the only place they go that has paper charts, and at first they’re a little shocked,” he says. “But once they realize that charting is simple, and they can come here and participate in patient care right off the bat without having to learn a new [EHR] system and password and all that, they really seem to appreciate it.”

His students are also reassured, Patel says, by the fact that he has computers in his office for other purposes, such as scheduling and getting patients’ lab results. “I’m not totally averse to computers, I grew up playing with them,” he says. “It’s just that I’ve gotten used to paper charting and I like it.”

Ann Cordum, MD

When Boise, Idaho internists Ann Cordum and Kristen Fiorentino began planning to open their own practice in 2015, one of the first questions they debated was whether to use EHRs. Both had used them previously and knew the technology’s advantages and drawbacks. Eventually they chose not to, though the decision was not easy.

“There’s a lot of pressure in medicine to use a formal EHR. But so far we have not felt that the pros outweigh the cons,” Cordum says.

In part, their decision was driven by a desire to keep their practice small and personal and operate it on a direct-pay model, which requires minimizing overhead expenses. And the costs of buying and maintaining an EHR system and keeping its software updated can easily run into tens of thousands of dollars.

“So if I can cut out that piece it allows me to see fewer patients per day and spend more time with them, which was our goal when we started this practice,” Cordum explains.

Moreover, she adds, EHRs require physicians to spend a portion of each patient visit entering often-irrelevant data such as when the patient last had an eye exam or dental checkup. “And the more time spent on all that, the less time the practitioner has to address the patient’s immediate concern,” she says.

In place of an EHR, Cordum has developed her own patient charting system, either creating a traditional SOAP note in Microsoft Word or dictating the note and sending it to a transcription service. She stores printouts of notes in her office and in digital form encrypted on her computer. Except when the patient grants permission, the only other person who can see the data is Fiorentino, when she’s covering for Cordum.

When Cordum needs to exchange patient data with another provider or institution  she does it the same way the other party does even if they have an EHR: by fax.

“It’s the irony of electronic health records that none of these systems talk to each other,” she says. “So even if I were totally electronic, I’d still be relying a lot on paper.”

Despite their shortcomings, Cordum says she’s not philosophically opposed to using EHRs. “If it’s a tool that will help my patient get better care, I will use it,” she says. “But if it’s cumbersome and not really helping the care, then it just doesn’t work for me and my patient.”

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