In health care, there are patients and doctors; machines and medicines; office staffs and insurance companies.
And binding them all together is paper.
In a given day, thousands of sheets -- lab results, referrals, billing information -- will change hands at a facility like University Surgical Associates in Chattanooga. The facility, home to 32 surgeons, spends close to $1,200 a month on paper.
That's why, for health care providers, entering the digital age is no small feat.
The shift from paper to digital has happened more slowly in medicine than in other industries.
But a federal program established under the 2009 economic stimulus law has provided billions in incentives for hospitals and physicians to make the switch to electronic records -- and in the next two years, it will begin penalizing providers that have not.
Overall, 291,325 doctors and 3,880 hospitals have made the switch, according to a Wall Street Journal report earlier this year.
The idea of digital health records comes with many goals: Greater efficiency, improved accuracy, more patients, faster billing, prompter payments.
But doctors' offices and hospitals say the transition has not been smooth.
Major changes have rolled out unnaturally quickly. Instead of less busywork, they see more. They worry about longer wait times, an overwhelming amount of data to sort through and less face-to-face interaction with patients.
"It is the single most disruptive thing I have seen in 30 years of practice," said Dr. Wayne Scott, who practices internal medicine with Galen Medical Group, which moved to electronic records more than a year ago.
Rae Young Bond, executive director of the Chattanooga-Hamilton County Medical Society, said she's heard the same story from doctors all over the region.
"The collective wisdom is that it will cut down on cost and improve efficiency. I don't think anyone sees that or feels that so far," Bond said.
At University Surgical Associates, physicians are reacting to the switch with everything from "enthusiasm to utter fear," said Dr. Chris Lesar, who has helped the practice make its transition.
Lesar hopes electronic records will be more accessible to doctors and keep them from having to "reinvent the wheel" every time they see a new patient.
Still, he said, "Anytime there is such a big change, it's a painful process."
In an age when everything from banking to filing taxes online is standard, the move to electronic medical record-keeping seems long overdue.
But Bond said it's harder to put traditional health records into such a format. For one thing, every person's health profile is completely different, medical codes are confusing and privacy laws are strict.
The American Recovery and Reinvestment Act in 2009 aimed to speed up the change by offering incentives -- and, later, penalties -- to providers who met certain criteria for record keeping.
In the first phase of the changeover, electronic patient records must incorporate checkups, details like weight, height, medications and certain behaviors, such as smoking.
At Parkridge Health System, doctors now log progress notes that can be viewed in real time, said Judy Rhyne, Parkridge Health System's director of advanced clinicals.
"The notes can now be much more comprehensive -- and they're legible," Rhyne joked.
She says the new system allows for better collaboration between doctors. It also is meant to cut down on duplicate testing, exposing people to fewer scans. Electronic prescribing can alert doctors if there's a dangerous drug interaction.
Another goal is more patient involvement, says Laurene Vamprine, vice president and chief information officer at Erlanger Health System.
Ideally, people could more easily have their patient records transferred when they move. They could more easily track their children's vaccinations and better care for parents living far away.
"This is something I think really could transform the way we look at health care," Vamprine said. "It probably would have happened anyway, but it's happening at a much faster rate."
And that faster rate is where the problems are, she said.
The new policies for electronic records are so complex, many doctors and hospitals say they have had to hire and devote staff just to get systems up and running.
The market exploded with hundreds of electronic records vendors after the incentive program was announced. University Surgical has taken a year to vet potential companies.
And it can be difficult to find a system that works for a particular specialty. Dr. Curt Chaffin, who practices at Asthma Immunology and Allergy in Chattanooga , said he has yet to find a system that meets an allergist's needs.
"We're not going to start using a system until we find another allergy doctor who is on the system and they like it," he said.
That practice can afford to go slowly, Chaffin said. It does not serve many Medicare patients and so won't see much in the way of penalties when the government begins cracking down on providers who aren't meeting new standards.
But others say they think the process has moved much too fast.
Scott, the internal medicine doctor, said his experience over 18 months on his medical group's new system is the opposite of streamlining: He's seeing 20 percent fewer patients and working 20 percent longer days.
"It takes longer to do everything," he said. "We have to check all these boxes, do all of this data entry. Instead of looking at the patient, I'm clicking through computer screens."
Even doctors who are very tech savvy are frustrated with the systems, Bond said.
In a large survey by Medscape last summer, 38 percent of doctors said they were unhappy with their electronic medical records system.
Still, some local doctors have viewed the transition as an opportunity.
Dr. Homero Rivas II said electronic records made it easier to open his new practice, Spine Surgery Associates. He doesn't need a file room and can keep a smaller staff.
"It's been easy for me starting a new practice from scratch," Rivas said.
He likes being able to access patient records -- even on his smartphone -- at any time, but says it's a trade-off: A paper chart can't crash, he said. And strict privacy laws mean the log-in process can be clunky and slow.
Still, he thinks the systems will work through its growing pains soon enough.
Providers say a major problem is that electronic records systems simply don't communicate with each other, defeating the point of more collaborative care.
That's why the second stage of the three-stage roll-out process should include the ability to share information with other doctors, and provide a portal for patients to review visits, see their prescriptions and pay their bills.
Some providers, like the Galen group, already have launched their portals. Others are rushing to reach that point.
The new standards for "meaningful use" must be in place by January 2015, when penalties -- in the form of reduced Medicare payments -- begin kicking in.
Which means all of the software vendors are sprinting to make major modifications, and hospitals and doctors offices are quickly having to revamp their systems as well.
"It basically means we have a year to do two years worth of work," Vamprine said. "Hospitals are scrambling. Physicians' offices are scrambling. Everybody's scrambling."
Many doctors don't want to rush because they don't want to have to go through the whole overhaul multiple times, Bond said.
"Some of the doctors I've spoken with are on their third system," she said.
Contact staff writer Kate Harrison at firstname.lastname@example.org or at 423-757-6673