Paper to EMR Transition

Step 1: Populate an electronic index of patients

Most doctors possess some kind of electronic index of their patients, commonly from billing or scheduling systems, and from which they will try to at least "seed" their EMR with a list of patients to whom care had been provided. Minimum "ported" information may be the patients' names, dates of birth, sex (gender), possibly their health insurance number(s), and possibly additional names (aliases) if these were supported in the source system. Possibly the dates of first service and last service (but note GNUmed does not at the present time hold any appointment information.)

The above depends on being able to get this information out of the old system, without having to pay ridiculous charges, and getting it in a form that will go into the new EMR.

One option by which to transfer and import the data would be in a "batch" mode. Th alternative would be on an as-needed basis if where single patients' data can, on demand, be exported from its origin and then imported into GNUmed. It is possible to define for GNUmed an importer template to understand the form and content of the external data. GNUmed also offers a "slave mode" if it is possible to get the source system to work with GNUmed. This is especially desirable if doctors are already using a billing or scheduling system that they may like to continue to use.

For most practices, proceeding with Step 1 should be delayed until you are going to combine it with some minimal additional functionality. Suitable minimum additional functionalities would be the tracking and maintaining of

• problem lists
• allergies, immunizations and medications
• incoming results (test data, reports)

As at April 2009, GNUmed manages problem lists and SOAP notes; it provides the ability to record allergies; a first iteration of medication recording is being coded; it already supports the import and signing of digital documents and allows the input and signing of test results. The import of digital (lab) results has been specced out and further work will help lab data import to happen.

Step 2: Stop adding new paper to the old paper chart

Before you even begin to worry about converting existing charts, you must first figure out how to stop adding paper to your charts. This means that you must develop a reliable system to intercept incoming paper and any other materials which would be printed (for example, incoming faxes) and a method by which to not need to add such new papers to what you will eventually be able to consider as "frozen" archival paper charts.

In this step, you must consider:

• paper arriving via mail, and hand-delivery, and via doctors' bags, and via patients both at the front desk and in the interview / examination room
• incoming faxes – see FaxIntegration
• online results / information which until now had been printed but which, if saved in digital form (perhaps print to pdf), could be imported as digital documents – see DocumentImporter

Step 2 only makes sense after you would have figured out and implemented in your EMR the bulleted items from Step 1.

Step 3: Choose how much archival paper to import

As far as how much more information to transfer from each chart, the options include getting the secretaries to transcribe summary information from inside each chart, where summaries already existed. The alternative would be to scan (e.g. into pdf) just the summary, or the entire chart, or anything in between the two.

Unless enough of the patients' paper charts can be scanned to make them functionally obsolete, the paper charts may have to be kept available on-site, in a so-called "hybrid" model.

Tips:

• some doctors who move to an EMR use the first subsequent visit of each pre-existing patient to populate the EMR with a problem list and to identify "key pages" for scanning.
• some suggest that the subset of pages that had been scanned be kept in a separate section at the front of each paper chart, in order to avoid later re-scanning what had already been scanned.

The transition can take between 6 months and two years. A lot of your processes (and those of the office staff) will need to be re-engineered.

References

Here is a link to a guide that is specific to my adjacent province of Alberta (in Canada) but a lot of it is generalizable:

http://www.cpsa.ab.ca/publicationsresources/attachments_policies/Transition%20to%20Electronic%20Medical%20Records.pdf

Another bit at:

http://www.advantageemr.com/advantage_emr_transition_brief.pdf

and a white paper from a tech consulting company:

http://www.usercentric.com/publications/downloadable/usercentric-ehr-white-paper.pdf