MO 250 Medical Records: Electronic Health Record Management Unit 2 Seminar

Introduction The information in an EHR comes from many different sources-physicians, nursing staff, medical assistants, technicians, and other allied health professionals working in laboratories, hospitals, insurance companies, and government agencies, among other settings. Moving from paper charts to electronic health records is a major undertaking.

Introduction (cont) Before beginning any conversion of paper records, it is important to determine which patient records will be included in the transfer and what information within each record should be converted (Sanderson, 2009). With that being said, let’s discuss the different approaches to record conversion from paper to electronic.

Discussion 1 1. What are some of the conversion strategies of converting existing charts to an EHR?

Discussion 1 Conversion strategies: Total conversion Incremental conversion Hybrid conversion

Discussion 2 2. There are pros and cons to each strategy; let’s discuss the pros and cons.

Discussion 2 (cont) Total Conversion Pros All patient data are converted at once and are available in the EHR Office staff members do not need to take time away from regular tasks to manually enter data

Discussion 2 (cont) Total Conversion Cons: The conversion of unnecessary data, such as data for patient’s who will not visit the practice again A higher error rate because of lack of in- house oversight of conversion.

Discussion 2 (cont) Incremental Conversion Pros Cost savings because the conversion is done by the office staff A smoother transition with less impact on day-to-day practice operation because the data are converted gradually.

Discussion 2 (cont) Incremental Conversion Cons: Occasional use of archived paper charts may be necessary. Not all patient data are available in the EHR at once.

Discussion 2 (cont) Hybrid Conversion Pros/Cons Some records may be outsourced, and others are converted in house With outsourcing you have to contract with a outside company for completion of all or part of a job Things to consider when outsourcing: cost, privacy, security, and loss of information.

Discussion 3 Once existing paper charts have been converted to the EHR system, live data must be recorded when patients visit the practice. What are some of the ways for patient information to be entered in an EHR?

Discussion 3 (cont) Dictation Clinical templates Voice recognition Document scanning

Discussion 4 Dictation and transcription remain the most popular ways to enter patient information into an EHR. Why do you think this is so?

Discussion 4 (cont) Dictation and transcription remain in use for a number of reasons: a. physicians are comfortable with a method they are accustomed to using: b. dictation is a narrative form which retains the detail, context, and comprehensive nature of medicine; and c. no additional training is required.

Discussion 5 Based on the question from the previous slide, how do you think this might change in the future?

Discussion 5 (cont) This may change in the future as new technologies become more common and the benefits become clearer.

Discussion 6 Are there any drawbacks to using dictating and transcription? If yes, what are the drawbacks?

Discussion 6 (cont) Dictation and transcription have several drawbacks: First, the are not immediately available. Second, there is a cost for transcription services Third, the transcribed files must be reviewed and edited. Fourth, if progress notes are dictated at the end of the day, or several hours after a patient encounter, detail may be forgotten.

Questions Any questions or concerns about the discussion questions for the week?

Reference Sanderson, S.M. (2009). Electronic health records for allied health careers. New York, NY: McGraw-Hill.