Chart Conversion

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EHR RoadmapWebEx
Stratis Health, the Minnesota Quality
Improvement Organization in partnership with
other QIOs, presents . .

• Chart Conversion

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Presenter

• Margret Amatayakul
• RHIA, CHPS, CPHIT, CPEHR, FHIMSS
• President, Margret\A Consulting, LLC,
  Schaumburg, IL
• Consultant to Stratis Health DOQ-IT Project
• Independent information management and
  systems consultant,
  focusing on EHRs and
  their value proposition
• Adjunct faculty College of St. Scholastica,
  Duluth, MN, masters program in health informatics
• Founder and former executive director of
  Computer-based Patient Record Institute,
  associate executive director AHIMA, associate
  professor Univ. of Ill., information services
  IEEI
• Active participant in standards development,
  HIMSS BOD, and co-founder of and faculty for
  Health IT Certification

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EHR Roadmap
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Objectives

• Appreciate the need to plan chart conversion
  early
• Identify all issues to address in planning for
  chart conversion (why, what, how, when, who,
  where)
• Evaluate current charts to develop a
  comprehensive chart conversion plan for your
  organization
• Assist clinicians in adopting a cost effective
  and efficient chart conversion strategy

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Chart vs. Data Conversion

• Chart conversion
• Making data in paper charts accessible/usable in
  EHR
• Examples Last two visit notes are available in
  EHR most recent hospital discharge summary is
  accessible through EHR immunization record is
  available in EHR
• Data conversion
• Making data already in electronic form in one
  system available to another system in electronic
  form
• Examples demographic and appointment data in
  practice management system is available to EHR
  lab results are moved to EHR

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Chart Conversion

• Preparation

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Chart Conversion Issues

• Chart conversion options
• Scan vs. abstract
• Staff/contractor vs. physician
• All of record vs. parts of record
• All records vs. active records
• Other issues
• Policy on chart availability after conversion
• Closing charts after conversion
• File records after conversion vs. warehousing vs.
  destruction
• Legal aspects

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Need for Chart Conversion

• Continually pulling paper charts
• Increases risk of lower adoption of EHRs
• Some clinicians may continue to write in or
  dictate for paper charts forever if they are
  continuously available
• Prolongs achieving benefits of EHRs
• Clerical staff redeployment cannot be
  accomplished if paper charts must continue to be
  pulled and filed
• Reduction in transcription expense is not
  achieved if paper continues to be the modus
  operandi
• Inability to access structured data in clinical
  decision support and quality reporting cannot be
  as thoroughly accomplished
• Increases patient safety risks
• A hybrid record situation is created where some
  records are on paper and some electronic, where
  potentially one physician covering for another
  may not be aware that the paper chart continues
  to contain current information

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Timing

• Although actual conversion must be timed to
  minimize the need to re-convert
• Very active charts should be converted as close
  to first appointment after go-live as possible
• Planning should begin early to
• Develop right strategy for organization
• Educate clinicians on conversion strategies
• Initiate chart conversion change management
• Prepare charts for conversion

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Chart Preparation

• There is much that can be done to make whatever
  chart conversion methodologies will be used
• More cost efficient
• More effective in capturing needed information
• Achieving greater accuracy and completeness of
  chart content transference
• Vendor selection does not have to occur to begin
  planning chart conversion
• In fact, planning the conversion will help
  identify functional requirements and applications
  desired in product
• For example does the vendor have an integrated
  scanning product or must this be acquired
  separately?
• For example does the vendor have a template for
  use in entering abstracted data that can then
  populate appropriate fields in EHR?
• The more time available to prepare charts for
  conversion, the easier the conversion will be
  performed

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Chart Preparation for Scanning

• Forms may need to be redesigned with
• Bar codes for indexing
• Changes in forms and/or ink colors
• Changes in font size
• Consistency in placement of identifying
  information
• Discontinue use of processes that require special
  preparation for scanning
• Shingling
• Stapling
• Non-standard size forms
• On next visit, dictate comprehensive note that
  will summarize all important elements of past
  history (that can be COLD fed into electronic
  document management system)

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Chart Preparation for Abstracting

• Merge any multiple
• Problem lists
• Medication lists
• Immunization lists
• Design special data capture forms
• To make data more legible for abstraction
• (P.S. Also begins getting physicians accustomed
  to template use)
• Begin checking accuracy and completeness of key
  data, such as
• Update allergy information
• Complete patient assessments

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Chart Conversion

• What, How, When, Who, Where

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Scan vs. Abstract (or Both)

• Scanning
• Easily performed by clerical staff
• Quickly makes paper records accessible
• Does not support clinical decision support and
  quality reporting functions
• Abstracting
• Requires some clinical knowledge
• More time consuming and prone to error
• Supports clinical decision support and quality
  reporting functions
• Most organizations use a combination

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Staff/Contractor vs. Physician

• Utilizing staff
• Supports retention and satisfaction of workforce
• Requires training extent to which depends on
  baseline skills and knowledge as well as scan
  vs. abstracting functions
• Availability may be an issue depending on timing
• Contractors
• Available for a price
• Often more qualified, but potentially not as
  committed to quality
• Physicians
• Should assume responsibility for preparation
  aspects
• May need to do some specialized abstracting after
  all other conversion has taken place
• Rarely routine unless special circumstances
  exist. Would need reduced schedule to accommodate
  routine

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All of Record vs. Parts of Record

• Rarely does all of record need to be converted
• Do evaluation on records following 80/20 rule
  (see next section)
• Recognize that converting entire record is a
  security blanket. Early planning, careful
  preparation, and consistently applied policies
  help
• Parts of record
• Generally, key parts of record for conversion can
  be identified for 80 of patient types 20 can
  be managed by exception
• Although potentially more costly to do part
  scanning and part abstracting, extent to which
  EHR depends on structured, discrete data may
  determine strategy

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All Records vs. Active Records

• Rarely do all records need to be converted
• Evaluate clinical practice
• Low revisit rate, convert records only
  immediately prior to appointment
• High revisit rate, define active records and
  plan conversion schedule
• Specialty may dictate how frequently active
  patients are seen, where they are in a course of
  treatment, and what data are required
• Payer mix and geographic location may determine
  need for chart reference

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Policy on Chart Availability and Closure

• Once a record is scanned and/or abstracted, it is
  usually marked as converted, then
• Not pulled except upon special request
• Pulled once or twice for quality assurance and
  marking of any additional forms to be scanned or
  data to be abstracted
• (Use different color post-its for physicians to
  mark charts for scanning/abstracting)
• Once a record is converted, it is also
  considered closed
• No new paper documents will be added to record
• Any paper documents received (such as from
  referring providers or new authorization forms)
  will be scanned and securely disposed

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Chart Archiving

• File records after conversion
• Most common, at least until next appointment
• May depend on cost/benefit of extent to which
  complete record is truly needed
• Warehouse
• Most common after first or second appointment
  following conversion
• Cost/benefit analysis should be performed to
  determine whether all records could be scanned by
  a service and only specified data abstracted
  often depends on nature of EHR and types of
  patients
• Destruction
• Usually performed after statute of limitations in
  state
• May be performed if entire record is scanned
• Should be performed on all new documents that are
  scanned

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Legal Aspects

• Most courts will accept scanned records as
  admissible under best evidence rule, just the
  same as microfilm or other miniaturization
• Statute of limitations applies to destruction of
  electronic records in the same manner as paper
  records, although most organizations maintain
  electronic records longer because it is feasible
• When planning electronic storage, plan for both
  back up and disaster recovery. Regularly test
  restore capability of electronic data. Rotate
  electronic media and format consistent with
  changes in operating system and applications
• Most courts continue to require paper
  representations of electronic records, so ability
  to generate a complete paper copy should be
  tested monitor this, however, as it is changing
• Because state boards of pharmacy vary in their
  signature requirements on prescriptions for
  controlled substances, some prescriptions may
  need to be scanned (in addition to templated)

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Chart Conversion

• Chart Conversion Plan

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How Do You Decide?

• List all forms in current charts. If high degree
  of variability among patient types, sites, etc.
  apply 80/20 rule of sampling
• Identify source of forms internally generated
  (you have control), from a hospital or regularly
  used lab, imaging center, pharmacy you may have
  ability to influence, from other sources you
  have less ability to change.
• Identify current format of forms are they hand
  written by physician, dictated and transcribed,
  faxed from another provider, sent via email or
  efax.
• Determine how you would like to access and use
  this data in EHR. Is viewing a scanned or print
  image sufficient, or must data be in discrete
  digital form for clinical decision support or
  quality reporting, or do you rarely expect to
  need it and it could be archived in paper form.
• Determine if this is a summary form, or form
  repeated on multiple visits in which case, how
  many visits back do you generally need access to?
• Identify when chart content should be converted.

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Chart Conversion Plan

• In addition to clinical needs, determine cost of
  all options some may be just as clinically
  acceptable and less expensive
• Minimize variability across clinic sites,
  specialty types, chart content to extent
  possible, to
• Reduce cost
• Reduce potential for error
• Train and test plan
• Begin to orient staff to chart content
• Enroll staff in medical/pharmacology terminology
  classes if necessary and available
• Engage staff in helping to design forms and
  prepare charts
• When starting to scan, test indexing and monitor
  quality of images. Verify number of records
  scanned equals number of records created in EHR
• When abstracting, test template programs and
  reliability of instructions

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Chart Conversion

• Chart Conversion
• Change Management

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Manage the Change

• Reassure availability of charts
• Sufficient staff to pull chart on demand (but not
  in advance of all appointments)
• Sufficient staff to support EHR training through
  the learning curve
• Count number of times
• Patients seen without charts
• Patients seen without labs or other results
• Patients seen without referring provider records
• Refills approved without reference to chart
• Urgent care delivered without information in
  chart
• Always remember, goal of EHR is quality
  improvement, so desirability for full
  availability of information even if never
  achievable is strong

Last Resort
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Stratis Health is a non-profit independent
quality improvement organization that
collaborates with providers and consumers to
improve health care.
This presentation was created by Stratis Health
under a contract with the Centers for Medicare
Medicaid Services (CMS). The contents do not
necessarily reflect CMS policy.