EMRs: Your transition from paper

Going to electronic records is more than flipping a switch. Practices must determine what do with old charts -- and how long to hang onto them.

During the change to an electronic medical record system, the focus for many practices is on how data will be collected, stored and analyzed going forward. But in most cases, there are many years' worth of historical data in paper files that physicians will need post-EMR.

Many practices are left wondering what data should be transferred to the EMR and how. And what happens to the data that remain on paper?

Jonathan Bertman, MD, a family physician in Hope Valley, R.I., who founded the EMR company Amazing Charts, said it's unrealistic to think that going live with an EMR and going paperless will happen simultaneously. "They are two separate things," he said. And people need to get used to the EMR before they feel comfortable walking in to see a patient without the crutch of a paper file, he said.

But the more information from paper that can go into the EMR, the better the experience physicians will have, said John Trudel, MD, assistant medical director of informatics at Reliant Medical Group, formerly Fallon Clinic, a large multispecialty medical group practice in central Massachusetts. However, it's unnecessary -- and in many cases cost-prohibitive -- to transfer every last piece of data when the chances of a physician needing it are low.

Though there are many ways practices have handled the transition, it comes down to three major decisions: what data get transferred, when and how the transfer occurs and how long the paper files continue to be used in the exam room. Experts say those decisions are based on a cost-vs.-benefit calculation.

What gets transferred?

What data are transferred into the EMR format is a question Dr. Bertman is asked by many clients. The answer, he said, "depends on how anal-retentive you are."

Kaveh Safavi, MD, North America health lead for the management consulting firm Accenture, said the data that are considered critical will depend on each practice and physician.

"From the doctor's perspective, the main issue is: Do you have the information you need to care for the patient at that point of care? And most doctors will say you don't need to see everything that happened in the past," Dr. Safavi said.

"If I am an oncology practice and these are patients that I am monitoring and have been treated over months, and lab values matter and chest x-rays matter, you have a totally different theory about how much information you need to see a patient. And if I am a primary care doctor, it might vary based on the age of my patients and the type of patients I see. There is no monolithic answer."

It's relatively simple when it comes to a solo practice. The physician decides what's important and what he or she can live without. But for practices with several doctors, and especially those with multiple specialties, experts say decisions about data should be based on a consensus that is reached by all physicians or specialties involved. And some concessions probably will have to be made.

"There's a significant cost to having people physically go into a medical record, look through the medical record and say, 'What do we bring forward to the new record?' because they had to actually physically go in there and type it in, so it's a labor-intensive process and very costly," Dr. Trudel said. His clinic was recognized for its use of health information technology as a 2011 recipient of the Healthcare Information and Management Systems Society Davies Award.

Robert M. Turner, DO, a family medicine specialist and co-managing physician of clinical information technology at the Kelsey-Seybold Clinic, a large multispecialty clinic system in Houston, said that before his organization's EMR system went live, the clinic decided to enter the data for the 100 most-seen patients of each physician. Of those patients, the extracted data were what they considered crucial, such as allergy, medication and problem lists, medical and surgical histories and immunization records.

From a medical-legal standpoint, the paper chart remains the official medical record of that patient for the time before the EMR implementation. Dr. Turner said. "So we only wanted to put things in the electronic medical record which we need to make decisions going forward about the patients." He said the EMR did not need to become a repository for nonessential information, since the paper charts still would exist, but the group didn't want physicians to start with an empty chart.

The when and how

A major expense associated with the transition to electronic records is the transfer of data. Whether a practice invests in bridge technology to smooth the transition, hires transcriptionists to manually enter the data, or brings on people to scan paper documents, data transfer probably is going to be a significant line item in the EMR budget. How the data transfer occurs will determine how much it costs, as each option varies in price.

There are different types of bridge technologies that can help with the transfer of data. Some are as simple as scanning technologies that capture the data and create files that are attached to the EMR; these can be queried using keywords or character recognition. Other, more complex technologies can scan the data and enter it into the EMR's data fields.

Sean Morris, director of sales for Digitech Systems, a bridge technology vendor, said most of the practices that use his products scan everything. There's no need to keep the paper files if everything is scanned, although most practices retain them for a year or two, he said.

Many practices either use their records staff or hire temporary help to scan old paper files. Dr. Bertman recommends scanning only important data in the beginning and manually adding other information to the EMR as each patient is seen.

The Kelsey-Seybold Clinic decided to use its physicians to do the initial scanning work.

Kelly Bruce Lobley, MD, pediatrician and co-managing physician of clinical information technology for Kelsey-Seybold Clinic, said having the doctors enter the data ensured the integrity of the information and helped them learn the new system.

For patients outside of the 100 seen the most frequently, their essential records were scanned into the system when they made an appointment. After each visit, the physician told the records staff if additional information needed to be extracted from the paper files and entered into the EMR.

Phasing out Paper

Most experts agree that it is not a good idea to phase out the paper immediately upon EMR implementation. Unless every piece of data contained on paper is going to be scanned, the paper records will have to be retained for some time. How long depends on each state's record-retention laws. But the time it takes for paper to be phased out of each clinical visit usually depends on the physician.

Michael D. White, MD, assistant professor of medicine at the Cardiac Center of Creighton University in Omaha, Neb., said that a year into the EMR implementation, paper charts still are used routinely during patient visits. The practice decided to make the charts available for the first two visits of each patient, after EMR implementation.

"Folks are much more comfortable having paper available so they can make sure the diagnosis and the problem lists were the same in both locations," Dr. White said. Once they see that the information is there, they believe things won't be so bad, he said.

The Kelsey-Seybold Clinic also made the paper charts available to physicians for as long as they needed them after implementation. Dr. Lobley referred to the paper charts as "training wheels" that made the physicians feel more secure. Most physicians phased out the paper charts after a year but can still request them. They can scan the paper charts for additional information that may need to be added to the EMR.

Reliant Medical Group also made paper records available for each patient visit for six months after implementation, and physicians still can receive paper charts upon request for review. Chris Diguette, director of application services for Reliant Medical Group, said physicians use the charts to check for discrepancies and validate that the data were transferred correctly.

Although the old records need to be retained for some time in some fashion, most of what is in them is probably not important, Dr. Bertman said. But trying to get rid of them all at once will not make for a smooth transition.

"The going-paperless thing is exciting and eventually is the key for most practices," he said. "Most of our long-standing practices are paperless, but to try and do that on day one or even in the first month or two is just asking for more headaches than it's worth."

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