Electronic health record (EHR, also called Electronic Medical Record or EMR) systems are rapidly being implemented throughout the United States. Despite this increasing adoption, paper is still in use in many places and for many purposes. The impetus for this study arose from casual observations in several ambulatory practices. Following the implementation of expensive and complex EHR systems, many providers and staff were still observed spending a significant amount of time and effort managing and responding to information on paper. This project aimed to examine the root causes and unintended consequences of the persistent use of paper following the implementation of an electronic health record (EHR) in the ambulatory environment.