The attention the healthcare industry now faces with regard to improving quality, safety and efficiency – and lowering costs in the process – has made the adoption of electronic health records a cornerstone of the Health Information Technology for Economic and Clinical Health Act (HITECH). Incentives are promised for organizations that demonstrate meaningful use of these systems, while penalties loom for noncompliance.

The burden of maintaining medical records in a physician practice is extreme. Overcrowded offices lead to inaccessible records; whether misplaced, lost, or in use by another staff member. Physician practices continue to seek a solution to reduce or eliminate the increasing volume of paper within their organizations. The optimal product would eliminate the issues of overcrowded offices and storage facilities, as well as the problems associated with paper medical records, like lost or misplaced patient charts. Physicians demand a flexible, easy-to-use solution, yet one capable of standardization for consistency and compliance. In short, physician practices need a solution that increases staff efficiency, productivity, and patient satisfaction, all while reducing operational costs.

You might be asking yourself what will happen with all the patient historical files that fill your file cabinets right now and are vital for the existence of your practice. Don’t worry, there is a solution to convert them to image files (PDF or TIFF). This solution instantly improves chart access and practice workflow by electronically scanning and filing your current documents, and making them accessible to your entire staff regardless of their location.

All files can be scanned and indexed according to your practice’s criteria: patient name, date of birth, Social Security Number. Indexing will help the retrieval of any patient record in a matter of seconds. After implementing EHR, all files will be attached to the patient’s profile.

Data and Document Management is a cost-effective way to meet those needs, by automation of patient charts, elimination of paper and growing storage spaces, and generation of a rapid return-on-investment (ROI).

Here are a few disadvantages of the paper records, and anyone who works with them could think of more:

• Only one person can have the chart at a time;
• Keeping track of chart location is difficult;
• Delays in r etrieving charts are common and aggravating;
• Handwriting is often illegible;
• Charts may be disorganized, with information hard to find;
• Some information doesn't get into the chart for many days;
• There aren't enough tabs for all the different types of forms;
• Many trees are sacrificed to print encounter forms and health summaries for each visit;
• Charts get very thick;
• Metal tabs break, and the charts fall apart;
• New volumes don't contain important old information;
• Back injuries from lifting charts have resulted in worker compensation claims;
• Paper charts that are left sitting around can easily be browsed by unauthorized people;
• Charts may be stolen or tampered with;
• Paper filing is time consuming and labor intensive;
• Chart files take up a lot of valuable space;
• Charts have to be retired just to save s pace.

FAQ

Q: Do we still have to pull the chart?

A: Yes, at least at first. The paper chart will continue to contain historical information of use to providers for some time. However, it is likely that after using EHR for 1-2 years providers will realize that they are not opening the paper record very often, and the facility will adopt a policy of pulling the record only upon request. In the short term some paper will continue to be part of the patient chart in the form of discharge summaries, consult reports, ER visits, and other outside records, as well as internally generated paper such as EKG tracings. Ultimately, EHR will include a document scanning and storage component that will provide electronic access to these records as well, leading to a truly paperless record.

Q: Do we have to print out notes and put them in the chart?

A: No. Certainly if some providers are using EHR and some are not, the latter may want to have electronically generated notes in the paper chart. However, this is time consuming, labor intensive, and unnecessary. Even those providers not using EHR to create notes can access the system to read them, and being encouraged to do so increases the provider's comfort level with the system.

Q: What about retention and storage of electronic records?

A: Currently, IHS has not yet developed an electronic records management disposition schedule to store health information contained in the EHR as it does for the paper record. If a patient record becomes inactive (usually after 3 years of inactivity), the health information should be printed out, filed into a folder, and sent to the appropriate Federal Record Center for storage or archive. This shall remain the procedure for archiving health records in an electronic format when it becomes inactive until IHS develops a disposition schedule approved by the National Archivist.