As many healthcare providers are relying upon electronic health record (EHR) systems for more efficient clinical documentation and on account of the incentive program for meaningful use, there is growing concern about migration of old paper charts into EHR. Information such as problem list, family history, social history, past medical history, allergies and medication are discrete data that must be entered from paper charts into the electronic record system in order to produce a useful record for the present and future. Providers can use either of the following methods for data migration.
Scan Paper Chart into EHR
Certain data including immunization history, EKG, recent CAT scans or MRI scans and possibly recent important consultation reports can be scanned into EHR. The provider can flag these items before, during or just after the first or second visit. Even though one may stop using the paper charts gradually, they can be stored off-site for retrieval, if necessary. The main advantages of this option are all data is in the EHR and it is possible to store old paper charts securely off-site. The disadvantages are:
- Since the data is stored in a graphical format (PDF), it can’t be searched using keywords in times of need.
- The files will have to be sorted after scanning and placed in the appropriate areas within the electronic record system.
Enter Data Manually into EHR
Data can be manually entered into appropriate fields within the EHR. Both nurses and physicians enter data from paper-based charts into electronic records. However, nurses only enter medications and allergies while physicians enter their own data. The nurses are usually fairly straightforward if the information is up to date in the chart. The disadvantages are:
- Nurses may not accurately enter the correct information
- Cost for nurses to perform this action
- Medical problems won’t be entered, which are required to be added by the physicians later
If physicians are entering the data, it is possible to have accurate data in the EHR. Phrasing and diagnosis are entered according to the individual doctor’s preference. However, this option also has the following disadvantages.
- Physicians will have to spend their valuable time for data entry
- It won’t generate any revenue
Providers using electronic records must make sure that the data within the system is accurate since a minor error can be populated very easily and malign the entire system. A professional medical transcription company can help in creating accurate reports from physician dictations and populate the appropriate EHR fields with transcribed reports. Outsourcing the task of transferring data from old paper charts to the EHR will prove cost-effective as well as save valuable time and effort for providers.
