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For other articles and previous issues click here. May 3, 2004 Is
It Cold Storage for Paper Records? Will paper ever become obsolete? It’s possible, but in certain situations it may be best to keep it around. Electronic medical records (EMRs) are here to stay, and many people believe that paper records are on their way out. Once a healthcare facility has decided to adopt an EMR, it must make many decisions related to its adaptation and use, beyond the decisions of which system to purchase or lease. “The Wall Street Journal recently reported that less than 20% of hospitals and 5% of physicians are using electronic medical records today,” states Kevin J. Palattao, vice president, Patient Care Systems, HealthPartners, Minneapolis. “Despite that, I believe that someday, in my lifetime, paper records will be something you see in a museum. In order to deliver the kind of care our patients expect and deserve, the healthcare industry must invest in the information technology of EMRs.” Should Paper Records Coexist
With EMRs? “In some cases, the elimination of a paper record isn’t the end goal but rather just the elimination of dictation or the elimination of all paper except chart note documentation,” explains Tracie Ellis, EMR sales manager, Misys Healthcare Systems, Raleigh, N.C. “In these cases, the physical chart may still be necessary. If, however, the ultimate goal of EMR is to eliminate the paper chart completely and generate all clinical documentation electronically, then the length of time using both paper charts and electronic charts can also vary based mostly on practice type. For specialists, EMR is generally started for brand-new patients, so the elimination of paper happens within a period of weeks. But for primary care providers, the elimination of paper charts generally takes at least six months. Again, the success of moving toward electronic records and away from paper is heavily based on a good project plan and commitment to the implementation of that plan. The best groups have a ‘we’re moving from paper charts no matter what’ attitude.” Active patient records may be transferred to an EMR, while the rest may be sent into cold storage. Some practices choose to transition all patient records into an EMR and shred all paper files and records, while some may opt to transition all records into an EMR but store the paper files. Still others prefer to institute a “start date” for an EMR, and all patient records and notes are entered electronically from that day forward. “Since it has been possible for my practice to scan or electronically link records to the EMR, we almost never need to pull a paper record,” says Teri Jacobson, MD, Issaquah, Wash. “Gradually, we have sent inactive charts to ‘cold storage’ while keeping, but never adding to, our existing paper charts. Gradually, active paper charts are transferred entirely to electronic records, though it would be easy to justify never doing so. The key is that we are reducing paper and space required for chart storage and can, as aggressively paced as we choose, rid ourselves entirely of the paper record.” Another factor in the decision of whether or not paper and an EMR should coexist is the type of EMR system that is purchased or leased. Some systems are more powerful and can handle huge volumes of information—such as many years’ worth of medical records—which can render paper records immediately obsolete. All necessary preexisting paper records should be scanned into the system before the EMR goes live, according to Ronald B. Johnson, MD, head of information technology at the White Memorial Medical Center OB/GYN Practice and Residency program, Los Angeles. His practice converted all forward-functioning record keeping to an EMR the day the system was implemented instead of using a gradual step-by-step approach. “It’s important to underscore what is obvious but often overlooked—that is, an EMR is not terribly useful until it has a critical mass of historical patient information in it,” Palattao says. “One key element of a patient-physician (and other provider) relationship is the free flow of information. Each organization must decide how much history is enough to effectively support the relationship and thereby support the delivery of high-quality care. “Another technical and operational consideration is the fact that you will likely have hospital, specialty, and diagnostic partners that are capable of providing only paper reports. So, a strong scanning and indexing plan is required if you want to retire paper records,” Palattao continues. “There is an enormous amount of workflow redesign that’s required, and old artifacts that must be removed, to make progress. For instance, the paper chart itself is an old artifact. If left in place, it will be a strong deterrent to progress. So, HealthPartners decided to simply stop filing records in the paper charts. In effect, this made the paper record less and less useful each day while making the electronic record more and more relevant each day. With our large amount of electronic history and a paper record diminishing in value, our caregivers made the logical choice: Use the EMR.” No More Paper? “Several Misys EMR offices operate completely paperless, meaning zero charts and zero chart space,” Ellis says. “Every single piece of documentation is either generated electronically or scanned into the electronic environment from paper or inbound electronic fax. For some specialties, like orthopedics, that rely heavily on x-ray images, in absence of a PACS [picture archiving and communications system], these images are generally housed in a chart sleeve for films. Even though a Misys EMR office may be ‘paperless,’ other offices or facilities that they deal with generally are not; therefore, it’s important to have a multifaceted scanning option that allows for quick and easy storage or imaging of paper documentation in an electronic format. There are plenty of offices where the majority of physicians document their visits electronically, but one or two physicians in the same practice do not. In those cases, both paper and electronic charts are needed, not because of software limitations but because of physician behavior.” Johnson believes it will be possible to eliminate paper records because the benefits of a paperless office will be too overwhelming to ignore. “Technology is increasing at mach speed,” he says, “and eventually, it will be attractive to even the most technologically challenged medical practices.” “Too often medical records need to be shared with other external organizations, which we would only transfer as a paper record. We get lots of data from outside physicians and have a need to use paper records as well as have electronic medical records,” explains Amanda Knox, systems analyst, Arizona Medical Clinic, Phoenix. “There is often a need to print from the electronic record to a paper record in order to attach an explanation of benefits to claims or in billing a secondary insurance. Too often we are required to print from the electronic record to a paper record because many insurers require paper document trails. Additionally, often referrals need to be faxed where we would need to print out a paper record in order to fax it.” Jacobson is optimistic that paper records will be eliminated one day. “The paper that is generated and sent to us by mail, much to our dismay, rather than electronically is almost immediately destroyed once reviewed and integrated into the EMR,” she explains. “The paper that other entities force us to process is minimal at this point. Someday we hope even the scanner will be obsolete in our office.” Benefits Outweigh Resistance “When Misys implementation staff comes out, they use their wealth of experience in matching up a plan that meets the practice’s goals… What are their hot buttons? Do they want to automate refills only or do they also want to start electronic documentation? Do they want to scan EOBs [explanation of benefits] before the docs start?” says Ellis. “Based on the goals, we tailor the implementation plan, and this includes the ‘weaning’ of paper and referencing and generating data electronically. “Most offices seek better access to information—this is definitely the No. 1 EMR driver,” she continues. “Typically, potential EMR users are looking to do one or more basic things: streamline paper-laden office processes that require a chart … pulling the chart for appointments, calling patients back, med refills; reducing transcription costs and lags associated with waiting for dictation; and providing better patient care through legible notes, orders, and improved responsiveness. Electronic charts can provide ‘alerts’ in ways that paper charts can’t. They can alert you that lab results are outstanding, patients are overdue for immunizations or Pap smears, or the physician just put an action item in your electronic inbox.” Palattao relates a story about how physicians at HealthPartners had their eyes opened, so to speak, as to the time-saving merits of an EMR. “I credit one of our physician leaders, Leif Solberg, MD, for a watershed moment in our paper record/EMR evolution at HealthPartners,” says Palattao. “What he did was create a survey titled ‘Physician Time Value.’ It was eye-popping. One of the central aspects of this survey was to solicit opinions on the things that waste physicians’ time as they try to deliver high-quality care. Six out of the top eight time wasters were related to the shortcomings of the paper record and its associated inefficient workflow processes. Eight out of the top eight time wasters could be dramatically improved with new workflows supported by information technology. The daily endurance run that caregivers have to endure to get the information they need from paper records in order to treat patients safely, efficiently, effectively, equitably, and with patient-centeredness is insane. We’re not perfect yet with the EMR route, but we’re making good progress. And it’s much better.” Electronic offices are more efficient and better organized, which means less frustration and time wasted searching for documents that aren’t there and no more shuffling paper or coping with stacks of paperwork. “When staff understands that this greater efficiency means cost savings, they are also pleasantly surprised that that can translate into better compensation to employees and providers,” states Jacobson. “My staff knows that when the practice does better, they do better; I think they feel more satisfied as a result.” Jacobson acknowledges that the present and possible future benefits of having an EMR outweigh any transition planning and investments. “What goals and objectives set forth in running a medical practice are not positively influenced by having a great EMR?” she asks. “According to just about every medical paper and journal, Medicare, malpractice carriers, and health insurance companies plan to provide incentives to practices utilizing EMR in the near future. That may help meet some of the financial objectives in our practices. Some professional societies act as advocates of the EMR so strongly that they team up with some EMR companies to give financial incentives in terms of cost savings in the initial purchase of their members’ software.” Johnson stresses the importance of choosing the right EMR system. “If you choose a system that does not have a complete range of features and functions, you will be met with chaos and staff dissatisfaction. If you try to implement a subpar system, users will revolt—no matter how well you implement the system,” he says. “I also think that you are best served by having a single individual responsible for implementation. Attempting to obtain a consensus of opinion at every decision point will make a smooth transition difficult and time-consuming. I think the future is limitless for the EMR. I can honestly say that the only questions my physicians and staff ask me now is ‘Why didn’t we start this sooner?’” More EMR Praise Palattao summarizes key steps in acquiring and implementing an EMR system, beginning with building a business case for investment in EMR technology, based on real savings, and then establishing a clinical data repository. Prior to implementing an EMR in any clinic or practice, care processes must be redesigned and workflow standardized. The fourth step is to just “bite the bullet,” he says, and stop utilizing paper files once an EMR is begun. It’s the only way to initiate complete EMR implementation and fully realize potential cost savings. Palattao suggests that everyone on staff may need basic computer skills training or refreshing—don’t assume that everyone knows how to use shortcuts or all the computer functions necessary for an EMR. And, last of all, realize and acknowledge the initial awkwardness barrier with EMR adoption. It will pass, and the EMR will come to be a fully integrated part of the practice, much like paper once was. — Laura Gater’s medical and business trade articles have been published in Medical Imaging, 24x7, Podiatry Management, Veterinary Forum, Corrections Forum, and other national and online publications. |
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