CareTracker Electronic Health Record (EHR) Planning Your Conversion from Paper Charts to Electronic Health Records

Transcription

1 CareTracker Electronic Health Record (EHR) Planning Your Conversion from Paper Charts to Electronic Health Records

2 Questions to Think About Who will convert the paper charts to electronic health records? What information do we convert from the paper chart to the patient s electronic health record? When do we convert the patient information to their electronic health record? How much of the existing patient paper chart do we move to their electronic health record? Ingenix, Inc. 2

3 Who Will Convert the Charts? Staff Temporary staff hire temporary staff assigned to this specific task Outsource - consider outsourcing the job to save staff time Ingenix, Inc. 3

4 What Information Do We Convert? Think about what information you look at with every visit Flow sheets with the patient's problem list, immunizations, and preventive screenings Progress notes Patient's past medical, family, & social history X-rays, MRI scans, lab results Ingenix, Inc. 4

5 What Information Do We Convert? Allergies complete the allergies section of the EHR at the first online visit Medication information patient s pharmacy can import from the patient s pharmacy benefit manager (PBM) - PBM must participate with Surescripts, patient must be eligible and have consent recorded medication history available if provided by the PBM for 1 year with prescriptions covered by PBM only Ingenix, Inc. 5

6 When Do We Move the Paper Records? Decide to move paper records either: Before EHR go live date After EHR go live date at time of patient appointment one week before patient visit patient s first electronic visit Ingenix, Inc. 6

7 Paper Charts to Electronic Health Records Easy as 1,2,3... When a chart is pulled.. At the time of the appointment At patient s 1 st electronic appointment One week before electronic visit Then Pull charts 3 times after EHR go-live 2. Date stamp each time after using the chart 3. File chart after using for the 3 rd time 1. Provide chart to physician 2. Scan identified parts of paper chart 3. File paper chart 1. Scan identified parts of paper chart 2. Give chart to provider for 1st visit only 3. File paper chart Ingenix, Inc. 7

8 How Much Do We Move? Identify limited items from patient s chart to scan Examples to consider for scanning: Lab results, imaging reports in the past 12 months The last annual physical note Last hospital discharge summary Home health care orders Practice specific flowsheets Ingenix, Inc. 8

9 How Much Do We Move? Specialty Reports Scan specialty reports from the patient s chart OB/GYN practices: pregnancy history Pediatric practices: growth charts Surgical practices: operative reports Cardiology practices: PT/ INR flowsheets Ingenix, Inc. 9

10 What Is the Best Way to Proceed? Three ways to move information from a paper chart to an EHR 1. Scanning images 2. Manually entering information 3. Combination - scanning images & manually entering information Ingenix, Inc. 10

11 Three Ways to Move Information 1. Scanning images Appear in EHR as it did in the paper chart can view image or data only cannot compare or graph to other patient information Ingenix, Inc. 11

12 Three Ways to Move Information Scanning Images Upload documents to the electronic health record in CareTracker: use the installed Attachment Tool or Client Batch Scanning Application with Bar Codes allows you to directly scan paper documents into particular sections of a patient's health record Use a visual indicator on paper charts to indicate data was transferred to the electronic health record Ingenix, Inc. 12

13 Consider Other Options Scanning Images If scanning all your patient paper charts at one time, consider the time consuming tasks... it entails prepping the chart -- removing staples, undoing dog-ears indexing images so they match up to individual chart tabs, setting up bar codes Select a few patient charts each day scan select pages from the paper chart, such as only the information you need for the next patient appointment manually enter other pieces of information Ingenix, Inc. 13

14 Patient Health History Questionnaire Scanning Images Ask your patients to do some of the work Time allotted for a patient visit is usually not long enough to recreate an entire medical history for the new EHR Based on how you are transitioning data/charts this could be done in advance or over several visits Ingenix, Inc. 14

15 Patient Health History Questionnaire Scanning Images Ask all patients to complete a new patient health history questionnaire Includes past medical, surgical and family history, meds, referring docs, etc Use this to complete the CareTracker Health History Pane of the patient s electronic record Scan it into the EHR Note: The practice can load their patient history forms into our Health Tracker Patient Portal, and in the future, patients will be able to enter their historical medical information online using the Health Tracker Patient Portal. Ingenix, Inc. 15

16 Patient Health History Questionnaire Scanning Images Benefits of new health history questionnaire Faster than trying to review the old chart Matches CareTracker s patient history section Captures all your patient's history review the electronic health record to be sure you have all the information Ingenix, Inc. 16

17 Important Points to Remember Scanning Images Don't let the office-based scanning get behind Fit scanning into the patient visit work flow as much as possible Send out large amounts of scanning (i.e. old charts) to a reliable vendor Ingenix, Inc. 17

18 EHR Patient Information Scanning Form - Scanning Images Sample of a label used to alert the transfer of information Patient Name: Date Information Entered Favorite Pharmacy Medications List Allergy List Lab Report Immunization History EKG Report Imaging Reports Pathology Reports Discharge Summary Annual Physical Exam Progress Note Referral Letters Health Care Proxy Other Ingenix, Inc. 18

19 Three Ways to Move Information 2. Manually enter information Enters immediately in electronic chart Can be graphed or charted with patient s other electronic information Information is now reportable Ingenix, Inc. 19

20 Three Ways to Move Information 3. Combination Scanning images EKG reports pathology reports Manually entering information discrete data lab reports, vital signs Ingenix, Inc. 20

21 Have You Been Using CareTracker s Billing System? CareTracker automatically adds ICD-9 codes (problems) to your patient s problem list in their electronic record You may want to keep the problem list current by updating to include the problem status (acute, chronic), date problem is resolved, and the state of the problem (controlled, fairly controlled) Problems are part of interaction screening so a current list will support clinical decision making Ingenix, Inc. 21

22 Prepare to Completely Adopt EHR This means not using any paper charts Have a redundant internet as backup Be prepared to use paper charts in case of emergency loss of electricity Decide a cutoff date for using paper chart retrieval Scan any paper documents as soon as they arrive to your practice Have only 1 legal record for any given patient on any given date. Chose a date, use the electronic record after that date, and make a final note on the paper record Ingenix, Inc. 22

23 Destroy Paper Charts Make a plan to file away and destroy paper charts Choose a destruction date for paper charts Note: Check your state regulations for dates of maintaining paper charts Define a logical plan for how to organize charts that have been transitioned to electronic records Ingenix, Inc. 23

24 Destroy Paper Charts Make a Plan Keep spreadsheets of what is boxed by year include in the spreadsheet list of all boxes charts inside boxes date electronic record was completed date when paper chart can be destroyed Review destruction boxes every 6 months for upcoming destruction date Use a company to destroy paper charts that has a positive reputation of being reliable and secure Ingenix, Inc. 24

25 What s Next? Get a shredder... For the paper you discard after scanning Better yet, subscribe to a shredding service Ingenix, Inc. 25

26 Comparing Strategies for Converting Paper Charts Action Continue pulling paper charts for a defined period of time Scan parts of paper charts Manually enter data from paper charts Use a combination of scanning and manual entry Pros Provider has last view Provider to pull paper EHR items Chart is organized by section Adds only pertinent and current data to EHR Not time consuming when scanning only specific parts Allows record to be stored for eventual destruction Makes data available to use in reporting and flow charting Achieves all benefits for electronic record Cons Time/staffing Mis-match e-record vs. paper chart Does not allow for clean break from paper to electronic Does not provide discrete data to flow in with electronic results For some period of time, a partial electronic record is formed, must keep paper Possible errors when entering data manually Time consuming May be confusing if not consistently applied Ingenix, Inc. 26

27 Thank You for Attending this Session