On the (Selective) Persistence of Paper

*I promised I’d share Toronto physician blogs if I found them, so here’s a GREAT one: Dr. Greiver’s EMR. She’s a family doc in North York and was recently featured on the CBC for her > 4 year documentation of the peaks and valleys of running with the Nightingale EMR (one of the ones subsidized by the Ontario government).

Today’s post is inspired by Dr. Greiver and a lifetime of paper-love.

There’s just something about paper. You can’t get rid of it.

A few examples:

I start reading many books on the computer and subsequently quit for a hard copy from the library.
Lifehacker polled its readers for the Five Best To Do List Managers, ostensibly looking for applications, and guess what came out on top? “Pen and paper.”
Stats Canada: “paper consumption has doubled over 20 years even as Canadians adopt new technologies”.

I think it’s safe to say that the paperless office/home is a myth.

Now, as EMR, EHR, PHR proliferate, there’s even more evidence that paper just persists…

I was especially reminded of this by Dr. Greiver’s latest post, which described some of the hardware that is required to keep her EMR going:

We have two scanners, two fax machines, and four labelers. We have twelve printers; nobody has to walk very far to get a printed document. Everyone has ready access to computers. All this is for a (paperless) three physician office.

Dr. Greiver’s definitely on the ball with all this equipment, but the description also shows that paperless isn’t really paperless. Paper is digitized (scanners, fax machines) + shredded, and it eventually has to come back out again as paper (printers, labelers). So when a practice adopts EMR, it doesn’t just toss the paper; it has to make choices about selective conversion and re-conversion.

This seems really tough, the more I read about it. Simply printing out the data you worked so hard to get into the computer requires hardware that needs to be well located and connected in the right way, not to mention updated consistently. I get confused with one printer, let alone twelve! Add to that scanners, fax machines, labelers, shredders…! What about double-checking scans (even optical character recognition is far from 100%) and making sure the pharmacist doesn’t get garbled mess for a prescription? Dr. Greiver even points out in another post that a physician has to get pretty comfortable with taking erratic leaves of the patient to grab this and that piece of paper wherever it spits out.

All in all, it’s a human factors issue, not just a technology issue. And it something to be managed, not endured.

Perhaps we need to further study why we’re married to paper to design tools to displace it.

Personally, I love paper because it makes me feel engaged. I don’t think it’s just because I’m a writer — to some extent, it’s just a feeling of ownership when I mark up a piece of paper or some other analog medium.

For example, some bloggers have talked about how parents responded very positively to the use of whiteboards to explain what’s going on with their child. All participants feel comfortable pointing to things, circling things, etc. At the end of the consultation, they’re invited to take a picture of the whiteboard – essentially digitizing the board. Dr. Greiver also mentions that using her tablet computer as a clipboard works well too.

If we imitate paper even with e-tools all around, maybe paper is here to stay. What do you think? What is the attraction of paper?

-Effy

Tags: Canada, EHR, electronic medical records, human factors, lifehacker, Ontario, paper, PHR, technology, toronto

Paul Kishimoto

It's not impossible to imitate the appeal of paper using technology, but historically the focus has been on developing purely virtual interfaces. No doubt you've heard of the Sixth Sense technology developed at the MIT Media Lab by Pranav Mistry. In this TED talk, he gives some idea of the motivation behind his work (e.g. at 10:50)—to paraphrase, technology which doesn't expose a tactile interface will always fall short. To model better behaviour, he moves data into the human environment.

This may be self-evident to those conversant with HF, but most software developers (especially of clinical software) aren't. Ebooks and electronic paper are technologies that I see as key to the replacement of paper: because the way one views these displays is very similar to the way one views real paper, they feel more natural than low-contrast, backlit colour displays with limited viewing angles.

The tactile aspect also explains the popularity of haptics in surgical training. Perhaps the contrast between the virtual and the real is keener in medicine, where doctors deal with the patient's body, than in other industries where technology has been more rapidly adopted.
Elizabeth Han

Amazing video, Paul. Thanks! Completely agree that the significance of the tactile aspect is felt especially strongly in medicine. I like that Mistry pointed out that interaction by touch is a quality that makes you feel human, for medicine is definitely a field that has entrenched attitudes about "the human touch". Many health professionals and organizations are super-wary of any technologies that seem to trivialize face-to-face encounters and direct modes of show-and-tell.
Timothy

Awesome blog post...I love how you format this post (and obviously the post itself). I find myself not spending enough time formating whatever I write into a presentable form for readers. My posts are like drafts. It seems like they are intended for my own reading pleasure.

Regardless, onto the topic of pen and paper. I think we have been (genetically? No idea) conditioned for millennia to hold some sort of writing tools, let it be a rock or a fountain pen, and script on some sort of medium, for the next reader. It may very well be possible that we absorb better when we read from paper (or bamboo sticks).

Something about holding that perfect pen and writing on that pristine sheet of paper. Just now, when I was explaining beam theory to my parents, instead of using the laptop, I elected to close the laptop and doodled on a piece of second cup napkin, using the lid of my laptop as a surface.

Lastly, merry Christmas and happy new year. Enjoy the east coast.
Elizabeth Han

Great points - the paper workarounds just feel natural. Or maybe it's the most stark reminder that the much-lauded technology must be further than we think from "usable".

hospitalSongs

On the (Selective) Persistence of Paper

Today’s post is inspired by Dr. Greiver and a lifetime of paper-love.

There’s just something about paper. You can’t get rid of it.

Now, as EMR, EHR, PHR proliferate, there’s even more evidence that paper just persists…

All in all, it’s a human factors issue, not just a technology issue. And it something to be managed, not endured.

If we imitate paper even with e-tools all around, maybe paper is here to stay. What do you think? What is the attraction of paper?

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