We investigated use of paper-based workarounds, and the underlying factors that contributed to their existence, at a Veterans Affairs Medical Center (VAMC). This particular VAMC was an ideal site to assess the use of paper with the EHRs , as it was undergoing an initiative to eliminate as much paper generation as possible to free space for new interventional radiology equipment in a location currently occupied by a paper file room. Atthough this VAMC used a widely integrated, nationally used EHRs , known as the Computerized Patient Record system (CPRS) , a substantial amount of administrative and medical paperwork was processed and stored by the facility. At the time this study began (August 1,2007), paper accumulated in a designated file room at a rate of approximately eight feet of stacked paper per week. In fact, this was more paper volume than the year prior to the implementation of CPRS at this facility in 1998, where about six feet of stacked paper was received by the file room per week. Larger patient volume and additional paperwork requirements contributed to the larger paper volume today despite the use of an EHRs. For example, the U.S. Department of Veterans Affairs (VA) Mandates that certain forms be printed and filed, especially if they contain original signatures. System workflow and EHR usability issues also contributed to paper generation. There are also many cases of "temporary" paper (i.e., paper that does not become part of the permanent record); this paper is eventually disposed of in the various sections of the hospital and not sent to the file room for storage.