The transition from paper to EHR is a major policy decision that can have repercussions on patient service, your operations and even your medical professional liability (MPL).
Unfortunately, many practices are not taking the time to analyze their options and responsibilities from a patient care and compliance standpoint. In order to set the correct framework for your effort, you should think about how you would answer questions about your paper chart transition strategy in order to prove due diligence in maintaining the patient record and/or in the transition from the paper chart to your EHR.
Disposition of the paper chart in the move to EHR
Many vendors encourage practices to move from the paper chart directly to the EHR. The vendors (and many doctors) take the position that the contents of the paper chart become obsolete with the EHR.
However, the physician and practice will be held accountable for patient care that could be affected by information in the paper chart. As important, a flawed transition from paper to EHR could compromise the designated record set for a patient or even all patients in a practice.
What were the decision factors that determined your paper record to EHR strategy?
How was the EHR vendor involved in the decision about the paper to EHR decision?
Was your paper record strategy and decision approved by the Chief Medical Officer and Practice Management?
What are the paper chart contents and other paper items (Ex. Logs and Registers) that you consider part of the patient paper record?
How do you provide access to information in the paper record that was not entered or scanned into the EHR?
What information on patient care or history that was not in the EHR was available in the paper chart?
Is it possible that subsequent information may be recorded into the paper chart that was not recorded in the EHR?
Selecting items to scan into the EHR
Many practices select specific items from the paper chart to be scanned into the EHR. In some cases, the doctor selects specific items in an iterative process. In other situations, the practice develops a list of items that should be scanned into the EHR and have various employees select the items to be scanned into the EHR.
How was the list of items to be scanned into the EHR determined?
In retrospect, what items were not selected for scanning into the EHR, but should have been?
Based on a review of the list of selected items, how could the physician determine the status of the patient from the scanned information when that information was not available in context with related items that were not scanned into the chart?
Who selected items from a patient’s paper chart to be scanned into the EHR?
Were the qualifications of the people who selected the items to be scanned?
How were the people who selected the items to be scanned able to determine the value and importance of a particular paper chart item?
What quality assurance activities were undertaken to insure that all of items were properly selected?
What quality assurance procedures were in place to insure that all of the items to be scanned were scanned and properly placed in the EHR?
What was the training program to explain the scanning strategy, and its limitations in caring for the patient? For example, if the chart contents from the last 2 years were scanned, how were the staff and doctors trained on gathering or selecting additional information from the paper chart?
Initially loading key clinical information into the EHR
In order to introduce a patient to an EHR, a variety of information may be needed to properly set up a patient and trigger appropriate care guidelines or protocols. For example, surgeons may want to record previous surgeries. Other doctors may want to record previous issues for a patient.
What was the basis for the information that was selected for entry into the EHR?
What information was transferred from the paper record into the EHR?
What was the source of information that was gathered from the chart? What confidence do you have in the accuracy of the paper chart source?
What interpretations and/or translations were required to accommodate the EHR structure when entering information from the paper chart?
What were the qualifications of the staff that located and interpreted the data from the paper chart to be entered into the EHR record?
What were the quality assurance procedures to verify the currency, accuracy, and interpretation of any information gathered from the paper chart for entry into the EHR?
What were the quality assurance procedures to verify the entry of information and representation of that information into the EHR?
ISSUE: Use of a Paper Chart After Conversion to EHR – In many cases, patient paper charts that have been used to start the patient’s EHR record are still used in the practice. Physicians and staff may use the paper charts to access information that was not scanned into the EHR, or as a convenience.
When are paper charts accessed for a patient that has already been served through the EHR?
Why are patient charts still accessed after the patient has been served in the EHR?
Does the paper chart contain information gathered after the EHR was in use that was not entered into the EHR?
Does the continued use of the paper chart call into question the completeness of the patient’s EHR based information?
Based on the use of both the paper chart and the EHR for patient care, where is the patient’s designated record?
The transition from the paper chart to the EHR has to be planned, analyzed, designed and performed in a manner that assures the integrity of the patient chart. Asking the right questions to frame your effort will prevent problems and issues going forward. Otherwise, you may have to answer more difficult challenges long after you thought that your paper record would become irrelevance.
Ron Sterling is founder of Sterling Solutions, which guides medical practices in the use of technology to improve patient services and practice operations.
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