Transition from paper to an EHR

We often get wound up in the details of how a particular Electronic Health Record (EHR) system functions, and how it helps us demonstrate Meaningful Use – so much so that we sometimes take for granted the difficult transition from paper to a digital platform in the first place.

Let’s say that all the traditional barriers to EHR adoption have been removed - there is no local IT infrastructure needed (no servers, no firewalls, no data backup, no securing of locally-housed Personal Health Information) because it is secure-web-based; and use of the EHR is quick, intuitive and easy to learn.

But even will all those barriers removed, there is still the challenge of making the transition – the “change management” barrier. Should all features be learned at once? Should there be a transition? What about the calendar? What about legacy paper documents that need scanning? These issues can easily vex a clinician, and stand in the way of full EHR adoption.

Fortunately, there is a growing body of experience in making this transition. Practice Fusion, whose business model relies upon helping new enrollees to become “power users,” hosts a growing community (tens of thousands) of clinicians who have successfully made that transition. From this experience, some common themes might be good to highlight.

Which calendar to use?
Practice Fusion (and most EHRs) come with a built-in calendar. This is useful for creating chart notes and billing messages from patient check-in. However, many billing systems also have a calendar (used for tracking billings). Some practices may also have stand-alone scheduling systems – even something as generic as Outlook calendars.

Moving calendar information to the EHR calendar is a recommended early step. The EHR calendar helps manage patient tracking through a visit – pending, arrived (in lobby), in room, seen, or no-show and rescheduled. “Arriving” a patient in the EHR creates a new (empty) chart note and billing message. When the EHR calendar is used as the main scheduling resource, then any calendaring functionality of a billing system can be abandoned. It doesn’t make sense to maintain two different systems – if there are multiple systems (EHR vs. billing), and these systems are not linked, then the EHR calendar should be the primary one.

Creating patient data
When you sign up with the EHR, you have an empty system. It is not really useful unless your patients are uploaded into the system. For brand-new practices, patient enrollment can be added as-you-go, one at a time. However, for an established practice that already has accumulated hundreds or thousands of active patients, then bulk uploading of patient data is important.

Where does this patient data come from? Likely, it comes from an output of a billing system. Most practices have been using a billing system for some time – it is a mature industry – either with in-house billers, or with outsourced services. If an output file from this system can be created, then it can be uploaded into the newly created EHR. This is an initial one-time step.

Once patients are uploaded, then the issue needs to be addressed of maintaining and changing that patient data. Again, the EHR should be the primary location of new-patient adds and edits (e.g. address, phone number, new insurance information). If the billing system is separate and not linked, then upon creation of billing messages, the biller (in-house or outsourced) can update the patient information in the billing system as the bills are processed – a manual process that results from disconnected systems.

What to do with old paper records?
Once the EHR is populated with patient information, and the calendar is in use, and the logistics of coordinating patient data between the EHR and the billing system are worked out, then the question arises of what to do with “all that information” locked away in paper charts.

Based on experience of best practices, the preferred way to scan documents into the EHR is via a phased approach, where both the paper chart and the e-chart are used side-by-side. If one uses a wireless laptop computer to display the EHR and carry it into exam rooms (which is about the size of a paper chart), then carrying that patient’s chart into the room is straightforward.

From “EHR Implementation Go-Live Day” forward, all new chart data is entered into the EHR. The paper chart is used as reference. Once the needed information is extracted from the chart, and selected items are flagged for scanning, then that paper chart can be retired, and not needed on the next visit. Over time (usually about a year), the need to pull a chart on a patient not seen since Go-Live Day diminishes and the paper charts can be moved to offsite storage. It is not especially efficient to go through all the old charts and scan everything – simply address each chart as patients are seen, and extract what is relevant.

Extra time and extra help at first
The most tedious step, at first, is getting summary data in the chart – diagnoses, medications, allergies, past medical history. Once those elements are in the chart, then subsequent encounters with that patient is much smoother. But the first time the EHR is used when seen an established patient, creating the summary data takes time. It is like every encounter is for a New Patient, the first time the EHR is used.

This is where slow-down is seen, regardless of the system being used. One approach has been to lighten the calendar, and schedule each patient as one would for New Patient encounters. Another is to anticipate the upcoming day, open each chart on the schedule in advance, and pre-load the charts with (at least) diagnoses and medications. Office help or data extractors can be brought in to help with this transition (a potential staffing cost).

Moving a clinical practice from a paper-based platform to a digital one is a significant decision. Once the EHR system is chosen, then several steps are needed to make the transition – moving patient demographic data, deciding on how to use the calendar for appointments, and deciding on how to transition the data from the paper stores to the new EHR. During a transition phase, there is likely to be a certain slow-down due to needing to create summary information (diagnoses, medications, allergies) in the new (empty) charts.

However, once the information is in the chart, then going-forward use of the EHR should only be a function of the usability of the system being used. At Practice Fusion, our interest is in creating an EHR experience that continually evolves in its ease-of-use, robustness and connectivity.