Going Paperless

Like a papier-mâché carrot, the promise of a paperless office was dangled before us for decades in our race to computerize our workplaces. Ironically, the idea now sits off-site buried under reports printed by the very machines meant to liberate us. But it’s still a good idea. To turn your paper into cash you’ll first need to lead your staff into new ways of thinking.

It won’t be easy. Paper, after all, is thousands of years old. Its presence in our history is physical, even metaphorical. Still, a laboratory with the newest technology using one of the oldest to store information seems off track, especially when secure, portable, and compact electronic storage is cheaper and faster than the “hard copy” we often prefer.

This anachronism began with the computer age. During the first decade of the personal computer, launched by IBM in 1981 and named “Man of the Year” by Time in 1982, paper use expanded nearly fivefold,¹ continuing to the present in which a typical office worker uses a sheet every twelve minutes,² a fourfoot stack at year’s end.

Your laboratory may be deluged by reams of reports, required or not, and they all cost you money. One hospital in Portland, Oregon challenged this idea by giving doctors a choice, cutting their output 23% and saving over nine thousand dollars per year.³

Getting rid of paper is good business because it is expensive to handle, sort, and store. But it’s hard to imagine a workplace without it, begging the question: do we really want a paperless laboratory?

Of course we do, if it saves time and money. But we work by habits that subvert choice even with a goal within reach. An analogy is computer conferencing technology, available for years yet sidestepped by the persistence of Victorian commuting habits. “The only difference now,” as noted in Inside Knowledge, “is that people can travel faster and further than they could 100 years ago, thereby creating a lot more pollution and destroying habitats, while suffering from higher levels of stress.”⁴

Retooling the paper paradigm

We’ve been told that the computer will shift our paradigm, or perspective that frames our decisions, from paper to digital media. Old and new paradigms are listed in Table 1.

Our thinking may indeed be changing. Paper sales have recently slowed from seven to four percent annual growth. One reason is nearly half the workers entered the market after computers were introduced. But that’s only part of the story. How information is stored is displacing human beings as filing clerks, making digital media not only ubiquitous but permanent.5 Trending suggests that paper is becoming a choice.

Before you can help your employees go paperless, there are several obstacles to overcome.

Age, for one. A quarter of our workforce will reach age 50 by 2010.⁶ But nearly a third of clinical laboratory workers are already over age 50.⁷ According to one study they are at least 15% less likely to use computers than coworkers age 30 to 39,⁸ suggesting a link between generation and technology gaps.

Accrediting agencies and individual inspectors may prefer paper, although this is changing. FDA rule 21 CFR Part 11, effective March 20, 1997, considers “paper records to be equivalent to electronic records, and electronic signatures equivalent to traditional handwritten signatures”⁹ By 2003, hospitals such as the Oklahoma Heart Hospital were using paperless charting and order entry with full accreditation.¹⁰

Ironically, the computer itself is an obstacle. Apple designed its 1984 Mac using a paper paradigm¹¹ of black text on a white background that resembles a typewritten page, file “folders,” and a “desktop” adopted as the standard. This imitation perpetuates our notions about the dominance of paper and suggests the adaptation of software rather than a lean flow of information. What was meant to buoy the user above an ocean of paper may now be an anchor.

But our prejudice isn’t simply rote, imposed, or designed. We may be holding onto paper (literally) for good reason. The authors of The Myth of the Paperless Office describe “affordances,” qualities that affect how we interact with an object. Paper, being lightweight and flexible, can be grasped, carried, and folded in a unique fashion. The authors suggest that rather than eliminate paper we integrate it with digital media.¹²

The above makes a “cold turkey” approach risky. But in changing how your employees think about paper you can take practical steps.

Redefining paper's role

Assumptions about paper can be redefined as a group, gathering ideas with brainstorming techniques. Asking your staff what paper means to them may make it easier for them to accept new thinking. Suggested new assumptions are listed in Table 2.

If using paper is perceived as a choice rather than an obligation, behavior can change. Envision “information work” instead of “paperwork” and you have the idea. Your employees will see paper as temporary information storage and not permanent in a physical or legal sense. They will realize that unless paper can be quickly retrieved, it is as good as gone.

Once your staff accepts that paper is temporary — more to the point, less permanent than electronic storage — they need to work around this new paradigm. It’s an overwhelming, even terrifying, challenge. After all, your laboratory may be designed around paper or your computer system may have been implemented to supplement, not to replace, paper.

The next step, then, is to redesign your existing processes to be paperless. You’ll need to use paper according to the new paradigm.

What does this mean? It isn’t enough to simply get rid of paper, although the amount of manual work attached to it suggests that any process will be improved by its removal. You may use it to track samples at workstations or record information in paper logs when the same information is in electronic form. Keep in mind that your goal is efficiency. Your processes should be redesigned to take advantage of electronic storage, saving you space, time, and money.

Using similar techniques used to identify assumptions, your employees can identify a “pilot” project to begin their transition to a paperless laboratory. The group can start by prioritizing their perceptions of where paper causes the greatest inefficiencies. Think of it as the first test of the new paperless paradigm.

After a process is chosen to redesign, the current state is mapped and then redesigned without paper that may involve purchasing or upgrading equipment. If new purchases aren’t immediately possible, make sure you establish it as a ground rule before you begin.

Example: your work group chooses sample flow at a chemistry workstation. The processes are outlined in Table 3. Note that the new process has fewer steps and less chance for error. This paperless process, moreover, by and large isn’t waiting for paper to continue.

This concept is illustrated by Figure 1, which plots these processes against time; the blocks represent paper steps. (Note that paper isn’t completely gone.) The schematic shows not just a shorter time span, but fewer potential delays, which is what paper steps really represent.

Planning is a good exercise, but how do these ideas work in the real world? The gap between thinking and doing can be wide for some employees. Here are guidelines:

• Reach consensus on the current state. List, map, or flowchart a process without a particular emphasis on paper.
• Map the “to be” process to highlight the strengths of electronic data storage, rather than simply eliminating paper.
• Give your employees permission to be paperless. “It’s OK to get rid of the paper” is quite a different message than “You have to get rid of the paper.” Supportive, encouraging language lets your employees know that they are making a choice at their own pace.
• Try incremental implementation to help make change less painful. For example, your employees may first try writing less information on paper or try saving it for less time.
• Expect setbacks. Your employees may find it too uncomfortable to get rid of paper, but they can always try again. Give them the freedom to adapt to a new process in a time span that they find non-threatening, and the change will last. 

Your goal isn’t to eliminate paper as older technology. Paper has a place in the laboratory, and what remains should be dated, stored, and purged when the time comes. Or it can be inexpensively scanned. A USB drive stores up to 15,000 images, and flatbed scanners cost under $100.

Changing your paper paradigm can provide the leadership to give your staff permission to use the technology at hand. Once they go paperless, they will never look back.

References

1. Comspec. Approaching the paperless office. http://www.comspec.com/6123.html.
2. Useful facts about copy paper. The Cutting Paper site. Available at: http://eetd.lbl.gov/paper/. Accessed 10/18/6.
3. Waste reduction activities for hospitals. The California Integrated Waste Management Board site. Available at: http://www.ciwmb.ca.gov/bizWaste/FactSheets/Hospital.htm. Accessed 10/22/06.
4. Wyllie J. The promise of computer conferencing. Inside Knowledge. 2003:7(2).
5. Bradley M. Whatever happened to the paperless office? The Christian Science Monitor. (12/12/05) Available at: http://www.csmonitor.com/2005/1212/p13s01-wmgn.html. Accessed 10/22/06.
6. Mature workers matter to economy. (06/18/06) The ocregister page. Available at: http://www.ocregister.com/ocregister/money/homepage/article_1184553.php. Accessed 10/23/06.
7. Best, M. Strategic laboratory workforce planning — you cannot afford not to do it. Laboratory Medicine page. Available at: http://www.labmedicine.com/headlines/ascpnews/0402.html. Accessed 10/22/06.
8. The aging of the US population and its impact on computer use. The Microsoft site. Available at: http://www.microsoft.com/enable/research/agingpop. aspx. Accessed 10/23/6.
9. 21 CFR Part 11, Electronic records; electronic signatures; final rule. Federal Register (3/20/97). Available at: http://www.fda.gov/cder/guidance/5505dft.pdf Accessed 10/24/06.
10. JCAHO awards accreditation to all-digital hospital. Tosay’s SurgiCenter page. Available at: http://www.surgicenteronline.com/articles/information_technology/562_341feat5.html Accessed 10/24/06.
11. Paper paradigm. The AllExperts page. Available at: http://experts.about.com/e/p/pa/Paper_paradigm.htm . Accessed 10/23/06.
12. The myth of the paperless office. The MIT Press page. Available at: http://mitpress.mit.edu/catalog/item/default.asp?ttype=2&tid=8501. Accessed 10/24/06.

Scott Warner is director of laboratory services, Penobscot Valley Hospital, Lincoln ME.