The journey to a fully implemented electronic medical record (EMR) will be long and challenging for all health care institutions. There are many issues to confront and overcome, such as justifying and securing the funding, selecting and implementing the appropriate technologies, and changing the processes and behaviors of the many participants in the delivery of health care to patients. The current processes make extensive use of paper documentation in the delivery and recording of health care; while the future may eventually eliminate the paper, we all know that it will be with us for a long time and may never be fully eliminated. This paper will describe a strategy for incorporating and integrating the paper documentation with the EMR in a manner that is cost-effective, flexible, and will bring immediate benefits to the clinical process.

The Challenge

In the vision of the fully implemented EMR, all of the clinical processes would be managed by fully automated systems that capture clinical data electronically, and those systems would be seamlessly integrated with the EMR system allowing the data to be fully shared. All caregivers would have an accessible and appropriate device allowing them to access and enter data as a natural part of their duties, and sophisticated security systems would control the access to the data in accordance with the institution's guidelines. So let's not quibble about how much the system will cost, who will pay for it, how the doctors and nurses will become willing users of the systems, what the technology solutions will look like, and all of the other real and significant issues that will be confronted. Let's just agree on two things: it will take a long time to fully implement an EMR; and during that EMR implementation there will continue to be paper documents that must be included in the patients' medical records.

Where are those paper records now? The answer is usually not a pretty one. The paper file for active and recent patients is usually stored somewhere near the clinical setting, such as a physician office, the outpatient care department, the medical records office, or with the patient. After some time, the paper medical records are archived in a more cost-effective manner. The typical alternatives are off-site storage of the paper or a conversion to either microfilm or scanned images. The problems of the current situation are well known: the records are not readily available to the patient's caregivers in differing locations, the medical records are often misplaced or misfiled, accessing archived records is slow and costly, and there is no integration with the clinical systems already in use.

The need is clear: to develop an approach for the paper records that allows them to be included with the electronic components of the medical records when clinical users are accessing the data, and to accomplish this with an implementation that is cost-effective and will be compatible with the technology to be deployed for the EMR system. New systems will continue to automate clinical processes and eliminate paper, but there will continue to be some aspects of care that will depend on paper records for the foreseeable future, and those paper records must conform to the EMR system.

The Solution

The recommended strategy to solve this need is to utilize imaging technology that can be integrated with the EMR system. Specifically, the paper records would be converted into digital images (similar to taking a digital photograph), each image would be tagged with the values for the key fields that will be used for linking and retrieving the record (such as medical record number, patient identification number, name, social security number, etc.), and the images would be loaded into a document management system for storage and online retrieval. The integration with the EMR system is accomplished by linking the data in the EMR and the images in the document management system via the key fields and having them automatically combined when the user retrieves the patient data. The following will elaborate on each of these steps.

The conversion to digital is the scanning process. The paper records are fed into a scanning machine (much like a copy machine) and a "picture" of the document is taken and becomes a digital image. Depending on the volume and the required time frames, the scanning can be done in the care setting (e.g., emergency room), in a shared services function elsewhere in the institution, or by an outside service bureau vendor. Archived microfilm images of paper medical records can also be included since there is a process to convert microfilm into digital images.

The indexes for each image are the key fields. These allow the systems to immediately find an image based upon the value of its key fields, such as patient name or medical record number (multiple indexes can be used to allow for optional means of accessing an image). The indexing can be done by the scanning operator (entering the index values for each image as it is scanned), or by a data entry operator after the images have been scanned and in a data file. Again, the volume and time frame for the images would determine the appropriate approach.

Document management systems are software products that are specialized systems for the storage and retrieval of images. They have very advanced features, are very flexible in meeting user needs, and are in wide use in many industries. Such a system would be deployed to store the images of the paper medical records. These systems are available from numerous vendors and can be implemented as an "in-house" or as a "hosted, outsourced" system depending on the preference of the institution.

The integration of the document management and EMR systems, while using common technology, is the very powerful feature of this strategy. It is this technology that allows for the patient data in the EMR and the images of the paper record to be seamlessly combined and presented together when the user retrieves the patient's data. The data in both systems would be organized using the same key fields making them logically linked, and the document management systems have standard features that can retrieve the appropriate images when a patient is accessed in the EMR. The effect is that the images of the paper records stored in the document management system are presented to the user as if they were a part of the EMR.

This strategy meets the need to integrate the paper records and the electronic records in the EMR system. It also simplifies the migration to the full EMR in several ways. The document management system makes it easy to add and remove the types of paper documents that will be stored on the system. During the implementation, document types (each different category of document is a document type, such as consent forms, discharge summaries, history and physical notes, etc.) can be added at any pace. Similarly, as the EMR system automates processes that are paper-based, the supporting document types can be eliminated from the document management system. The images are stored in an industry standard, non-proprietary format allowing them to be converted to an EMR system's imaging component if that is ever needed. The documents can be viewed (and integrated with the EMR system) with any PC with standard Web browser features. And the integration features of the document management systems can work with any EMR system, allowing the institution to begin using imaging to manage the paper medical record even before the EMR system has been selected.

The benefits of integrating the paper medical records with the EMR patient data are obvious. However, there are benefits to utilizing imaging instead of paper that will also be realized. By having the images of the paper record stored in the document management system, they can be accessed simultaneously by multiple users. They can be immediately retrieved from any location, and the files will not get lost or misfiled because they are not being handled after the scanning process. In addition, the system provides for backup and disaster-recovery protection. These are all significant advantages over the existing paper-based processes.

Figure 1 provides a schematic representation of this solution.

Conclusion

The strategy of using imaging technology to immediately begin to manage the paper components of the medical record, and to integrate with the EMR system once it has been deployed, provides a very sensible and pragmatic approach. The full implementation of the EMR will have many discrete steps and will take many years. During this time, the generation of paper components of the medical record will continue, and their storage and retrieval should be compatible with the EMR system. The strategy described in this paper addresses the problem with a flexible solution that supports the institution's path to the EMR and provides immediate benefits to the clinical users and the medical records department by eliminating the management of the paper file. It also provides a technology path that can be implemented immediately and is compatible with an EMR system of the future.