A Scanner Darkly

September 13, 2010 at 9:12 am Leave a comment

The awkward phase. It’s an unpleasant nebulous moment between two well-defined points. That uncomfortable time as people go from childhood and adulthood. Or that fearful moment full of panic as you go from dating to being in a serious relationship with someone else. It’s that interim state where you’re no longer A but you’re not quite B either.

Medical reporting is currently in its own awkward phase.

In the not so distant past lies Paper Based Reporting – filling out forms using pen and pencil, typewriters, printing out reports and having physical copies of every document located somewhere. This is the world of triplicate, of faxes and envelopes, of white-out and paper shredders. Paper charts physically shipped or moved from practice to practice, facility to facility. Paperland, as I like to call it, does have its advantages, though: a physical document that proves that something happened and to which people can refer; an artifact that precisely records how something occurred at that date and time, without any fear of tampering; a collection of data that cannot be wiped out by a virus or any sort of IT snafu.

Meanwhile, in the not so distant future lies Electronic Based Reporting – entering every information via computers. Using synoptic reports to enter structured data, information is culled directly from machines (think of vital signs being automatically recorded and logged), or easily entered using touchscreens, mouse & keyboard or a stylus of some sort. Electronic reports allow for faster sending of information to a wider range of places. Specialized fields ensure consistency in language and information captured. Required fields and “checklist” approaches encourage more completeness in reporting and more pertinent information is readily captured.1 However, Tronworld, as I’ll refer to it, has its own share of problems. Information can be lost or stolen without any physical backups. There’s ensuring that all systems are speaking the same language when interfacing, so there’s no loss of data or need to reformat the data every time you go from one system to another.

So, between here and there, betwixt Paperland and Tronworld, lies us currently. How are people bridging the divide between the two different modes of reporting? The answer…might surprise you.

Actually, it probably won’t, as the answer is in the title of this post. Right now, most medical personnel are using an amalgam of solutions to record the information. By combining paper documents, some electronic solutions for specific tasks, and scanned pages, facilities and practices have created electronic files for patients. This mish mash of formats and document types tends to be literally be like Frankenstein’s monster – unwieldy, hard to manage and deathly afraid of fire.

But the main bridge used to gap the two worlds, the temporary solution utilized in creating the foundation for an electronic health record, appears to be scanning. In order to begin the march towards total electronic medical records for everyone, we have to ensure that all previous information is added into the new electronic space we’re moving towards. And all that previous information, all those charts and sheets with their ink spots and handwritten notes – all of that has to somehow be translated into the new digital environment. The easiest way is through scanning, taking the paper copies, scanning them and then saving the form as an image in a particular file/folder for that patient.

It’s obviously a stop-gap measure – the only practical response for ensuring that documentation lives in the (preferred) electronic formatting, without having to re-enter each point of data. And for some, it’s more than just catching up on previous documentation; some facilities scan documents in to EHRs for current patients and procedures. It appears like the best of both worlds – the unique comforts of paper forms married with the reliability and portability of a saved electronic document. It’s such a draw that we have had to incorporate it into our demonstration of mTuitive OpNote. Our product produces a postoperative report that is saved to servers, but also can be turned into a PDF and then printed – for paper filing or to be scanned into whatever database the facility is currently using to store such documents. Our CEO, John Murphy, refers to it as the “poor man’s interface” and we try to discourage that term as it conjures up images of a Health IT Hobo. We agree that it is a common solution found in many facilities, we just object to the phrase – it’s not the most flattering of images.

However awkward the phrasing may be, Mr. Murphy is correct – it is a type of interface. The dictionary has multiple definitions for “interface” including communication or interaction and “a thing or circumstance that enables separate and sometimes incompatible elements to coordinate effectively.” In that sense, scanning is an interface, a way for the paper document to live in the electronic space. But is it a good interface?

Using scanning as the stop-gap measure brings with it a few problems – one of which is staffing. Who’s going to be scanning in these documents? Most non-medical employees of health facilities and doctors’ practices already have more than enough tasks to try to cram in to their 8 hour day. It’s one thing to incorporate a step into the current workflow; before filing a form away, put it into the scanner. But what about catching up on all the documents of the past? Incorporating all of those documents into your present EMR is a mammoth undertaking that will take many hours of scanning.

The most common solution to this problem is to hire temporary staff to just sift through the pages and scan the pertinent documents. But how helpful is this solution? Joseph Meewes, president of National Scanning, outlines many of the problems in this post, and puts forth what questions facilities should be asking when utilizing temporary help for scanning these documents. Mr. Meewes argues that if your organization is seeking help in scanning documents into its EMR, then be sure to use companies and people who are aware of the importance of these documents and understand the need for precision in scanning each piece. As Mr. Meewes writes,

Transient help is cheap, but they have no responsibility to monitor quality, ensure that records are properly filed & attached to EMR, or to ensure that misplaced records are found. We even worked with a physician who had temporary help literally throwing charts away to create the illusion of higher productivity.

It’s important to note that this isn’t true of all temporary staffing. But there is a need for precision and completeness with medical records – not just for the patient’s health and treatment, but this documentation also has legal ramifications for the doctors who treat that patient. The article goes on to discuss how incomplete records count as “professional misconduct” and gaps in documentation weaken risk management should any litigious action occur.

Building on Mr. Meewes’ post, is this study from the American Medical Informatics Association which examines the “Effects of Scanning and Eliminating Paper-based Medical Records on Hospital Physicians’ Clinical Work Practice.” Using scanned documents is helpful – allowing doctors to find information for their patient in a relatively fast manner using local computers. However, there are some drawbacks – mostly centering on time and the format of the scanned document. It took too much time for the physician to go through each of the scanned items. And, once a physician did find the relevant document, due to the format of the document (as an image), there wasn’t much they could do with the content. And since each document was now a scanned image, without the proper software/program installed, there’s no way to search looking up keywords, or to find the document if it hasn’t been properly titled. The potential of these documents can’t be unleashed due to its static nature, which clashes with the ever-changing dynamics present in healthcare. The study sums up the current status of using scanned documents thusly:

The images should, therefore, be considered an intermediate stage toward fully electronic medical records. All considered, we believe that such a scanning project can be justified by the increased availability of patient data to the physicians and the faster transition to full utilization of an EMR. The reported disadvantages of the scanned documents may diminish over time as their contents become outdated.

The awkward phase. We’ve all gone through it in some form or another. It’s the moment when you don’t belong in either category, so you just get by with being a hybrid of the two.

Health IT and medical reporting is in a state of transition. Digital eyes trained on the future while analog hands keep working in the present. This point of departure between the two, that vague no man’s land which is the best and worst of both worlds, is where we currently find ourselves. Health IT finds itself in the intermediate stage between potential and actuality. Scanning assists us in our reporting, and it helps people get used to seeing reports on a computer, but it cannot be the destination; ultimately doctors will have to be able to access and utilize the data in those reports, and the extra steps (with its added staffing and budgetary costs) will have to be removed in order create a more streamlined process. Until then, we just have to get through our awkward phase and hope that the future won’t judge us too harshly and we learn the right lessons from today’s missteps.

1.Dermatol Surg 2007 May;33(5):588-95.; AnnSurgOncol 2004 Oct;11(10):941-7.; Surgery 2007 Sep;142(3):420-1.


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