What if healthcare’s Holy Grail is a paper cup?

Sept. 18, 2010

Is paper the healthcare industry's enemy? Probably not, but it seems as if it's the industry's longstanding target for everything bad.

At times, it feels as if I've made a career out of writing about the healthcare industry's quest to rid itself of paper. It started back in the mid 1990s when I served a brief stint as editor of this magazine. I left the magazine in 1996 to create my company that focuses on writing about health information technology (IT), and I have been doing that ever since. On a fundamental level, the recurring theme in most of the topics that I've written about during the past 16 years entails some clinical, financial or operational component that focuses on using technology to reduce or eliminate paper-based processes.

I'm thinking about my career because this year marks the 30th anniversary of Health Management Technology magazine. It's a significant milestone, considering the numerous competing publications that have launched and subsequently gone out of business during those three decades. I was the editor of the magazine during its 15th anniversary, and much has changed within the industry since then. However, I'm surprised by how many of the same industry challenges remain unresolved, and that the industry still pursues its quest for the Holy Grail.

If millions of Americans can manage their lives from the convenience of a smartphone, why can't the healthcare industry achieve widespread implementation of EHRs and HIEs that rid the system of paper?

Is healthcare's Holy Grail a mirage?
The Holy Grail is envisioned by some as a sacred cup, but the term is often used as a metaphor signifying an object or goal of great significance. Healthcare's Holy Grail is clearly a metaphor — the ideal that the sudden development of a new technology or concept will quickly revolutionize the industry. It's also a mindset, where people within the industry keep looking for — and expecting — “the next best thing” to come around the corner. As a metaphor, it's unrealistic. As a mindset, it's a distraction. Innovation should be embraced when it provides value, but simply adopting technology because of its hype distracts organizations from initiatives that actually provide value.

I'm still waiting to witness the arrival of a revolutionary technology. Sure, there have even been some game-changing innovations, such as the Internet and computer hardware's exponentially improved price-to-performance ratio. But overall, technology advancements have been largely evolutionary instead of revolutionary. And as technology evolves, so does the terminology that is used to describe it.

Ideas get recycled, but terminology changes
In 1995 and 1996, I was writing about how the industry was poised for widespread adoption of computer-based patient records (CPRs) and community health information networks (CHINs). Both were supposed to greatly reduce paper-based processes. The funny thing is that I'm still writing about those things, except now they're called electronic medical records (EMRs) and health information exchanges (HIEs). Or are they?

Some prefer to use electronic health record (EHR) as a synonym for EMR, while others contend that they are different solutions. Likewise, many insist that there is a distinction between HIEs and regional health information organizations (RHIOs). Apparently, I'm not the only one who is confused. The Office of the National Coordinator for Health Information Technology (ONC) spent nearly $500,000 in 2007 and 2008 to have organizations develop precise definitions for the terms. In the end, I'm not sure if the ONC's effort or expenditure decreased the industry's confusion.

Of course, today's EHRs and HIEs are mature versions of their predecessors. Regardless of what they're called, EHR and HIE initiatives have been two of the industry's priorities for nearly the past two decades. Now, their priority is further elevated with the availability of government stimulus funding under the American Recovery and Reinvestment Act (ARRA). Like many of the industry's key initiatives, much of these efforts focus on decreasing or eliminating paper-based processes.

Is paper a scapegoat?
Perhaps paper is just an easy target. Eliminating paper-based processes is a simple concept for the public, politicians and investors to understand through brief sound bites. Politicians tout the benefits of EHRs and HIEs in their speeches. Investors hype companies with potentially transformative technology. Consumer media outlets portray the implementation of EHRs to be as simple as installing an application on a desktop computer or accessing a Web site. These oversimplifications add to the public's perception that the healthcare industry is dragging its feet. After all, if millions of Americans can manage their lives from the convenience of a smartphone, why can't the healthcare industry achieve widespread implementation of EHRs and HIEs that rid the system of paper?

The trouble is that the industry-wide elimination of paper sounds simple, but it's not easy and perhaps it's not even practical. I'd like to think that the industry's major initiatives have much broader goals, such as improving patient outcomes and reducing the cost of care. And for the most part, I believe that the industry (software vendors included) is pursuing those broader goals. However, explaining the complexity of those initiatives does not make for good sound bites. Further complicating matters are the numerous competing perspectives on the subject, including providers, payers, vendors, investors, patients and the government. Rarely do all of these perspectives align. That creates a tremendous amount of pressure for today's healthcare organizations. Additionally, there are often incentives — occasionally even large financial incentives from the government and other entities — that pressure organizations to align themselves with the priorities of others.

The oversimplification of healthcare's complex issues allows paper to be an easy scapegoat. Like healthcare's Holy Grail, paper has become a metaphor. If the expectations for healthcare's Holy Grail are for a truly paper-free industry, I doubt that I'll live long enough to see that day. For me, I like to envision healthcare's Holy Grail as a paper cup. It's a good sound bite, and the irony of that suits me just fine.

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