Mailer and Me: Do You Have Any Paper?

About 15 years ago I was covering a political event in California, and I sat near the top row of an auditorium, with a curly haired gentleman behind me. I knew who he was right away, but I didn't bother him. He was writing on some scraps of paper.

At one point, he interrupted me in a somewhat gravelly voice, "Do you have any paper?"

"Sure," I said, and I lent him some scraps of my own paper. Two reporters just doing their jobs.

"Thanks," Norman Mailer said.

If we were covering that event today, probably no paper would be involved, and Mailer and I wouldn't have exchanged any words. Oh maybe, he would have been carrying a computer, and asked, "Is there any electricity?"

And for more and more physicians, the paper chase that the late author Mailer and I engaged in so long ago is nearing the end of the line.

The government is pushing EMR as an enhancement to healthcare. There are some conflicts, however. A recent study in The Journal of General Internal Medicine shows that "a gap exists" between policy makers' expectations that commercial EMRs can improve coordination of patient care and clinicians' real-world experiences with EMRs. The current fee-for-service reimbursement encourages EMR use for documentation of billable events, such as office visits or procedures, and not for care coordination, the study says.

In addition, the Center for Studying Health System Change states EMRs may have unintended consequences for care coordination, such as creating information overload that complicates providers' efforts to discern key clinical information. It adds that managing information overflow from EMRs is a challenge for clinicians.

Excuse me; have you tried to manage paper?

Larry Garber, MD, at Fallon Clinic in Worcester, MA, oversees the flow of records for his practice, and he's tried to do both over the years, paper and electronic, and he's seriously leaning on the electronic side, no joke. As well as being an internist, Garber is officially medical director for informatics at the clinic, which is an ambulatory, multi-specialty group with more than 20 sites across central Massachusetts.

He's implementing an EPIC system, which provides a computerized electronic health record for every person who visits Fallon. Generally, he's found that EMRs are working for patients as well as for the income of the practice.

Garber doesn't agree with the "generalization" in the Center for Studying Health System Change report that suggests "all" EMRs have problems, as opposed to just some EMRs. Garber says his practice is enthusiastic about its EMR system.

"I do agree that the way we're paid (based largely on the length of our documentation) forces physicians to create voluminous notes that can obscure medical meaning," he says. "This is no different than the paper world; but is just easier to accomplish in the electronic world. When all of the healthcare insurers switch to paying us for caring for a population of patients, then we can remove much of the documentation clutter."

The transition from paper to electronics doesn't happen over night. Fallon said his practice spent years implementing the program, and allowing time for members of the practice to get accustomed to it. Most did. Over the first three years of EHR implementation, which began in 2001, Fallon's group spent $24 million investing on the program. The investment has been worth it, he said, referring to its EPIC system. "We reduce information overload because in the paper world, hospitals send the primary care physician everything including numerous test results and consult notes that take place during the hospital stay," Garber says.

"But with EPIC, we file most of those silently into our electronic health records for future access if necessary," he says.

There are some stumbles along the way. As his physician group was moving toward an electronic system, there was a "surprising realization," Garber says. Doctors were still dictating their notes into a voice recorder, and they had to send out transcriptions overseas. So even though the practice was on an EPIC system, it was still spending an extra $10,000 per physician, not to mention the lag time in retrieving the documents. Not good, Garber says.

In 2008, Fallon Clinic launched a Dragon Medical speech recognition program, which provided 10 diverse physicians with medical to dictation directly into the EPIC system, versus typing, or traditional transcription support.

Among other things, it found a 99% reduction rate in the average number of minutes after a patient left for the final note to be placed in the EHR system. For the physicians, that meant the wait time went from an average of 3.8 days to 46 minutes. The net savings: $7,114 per physician each year, according to Garber.

Besides the inevitable cost savings, Garber says that the electronic records ultimately serve the top priority, the needs of the patients. Garber says he "diagnosed several (patients) with prostate (issues) that would not have been caught as early," thanks to the electronic health records. Because the records track a patient's history, he noted he received information about a patient's "motor vehicle accident that the person didn't tell me," he says.

So the electronic record is the way to go. Even Mailer did it eventually, in his own way. When he wrote his first book, The Naked and the Dead in 1955, he typed it. Later he hired a secretary who eventually maintained what would become "all of the electronic records," according to the Harry Ransom Center, at the University of Texas at Austin, where Mailer's papers are maintained. Mailer died at age 84 in 2007.