Guest Post: Scanning Paper Charts in an EMR Office

One of EMR and HIPAA readers, John Meewes, was reading some of the comments on my previous post, “Paper Chart Disposal After Implementing an EMR” and wanted to provide a scanning companies perspective on what he’s seeing in the market. The following is his guest blog post on the subject.

Discretionary scanning, hiring temporary help, and re-purposing office
staff to scan patient charts has been a growing trend.

While the costs associated with these practices may at first glance seem
lower, there are hidden costs and liabilities that far outweigh the
expected savings.

When selecting a scanner, the first number potential buyers see is the
“Pages per Minute” (ppm). This is the number of sheets that the scanner
can read under optimum conditions (and usually at lower resolution and
page size). The number usually not published or ignored is the daily
duty cycle – often just several thousand pages per day.

In real world settings, the actual throughput is less than 1/4 of the
published PPM. Jams, indexing, and software glitches all slow the
process. Equipment maintenance, software installation, training, and
employee turnover further add to the time spent on the scanning project.

As labor costs (which are a function of throughput) increase fourfold or
more, the ROI model that may have initially shown cost savings with a
“do it yourself” project may no longer support that decision.

Most importantly, though, is the liability physicians face for
improperly scanned charts. 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.

Physicians are required by law to maintain a medical record for each
patient which completely and accurately documents the person’s
evaluation and treatment. The failure to maintain a record for each
patient constitutes professional misconduct. A missing chart could
have serious consequences on the provider’s ability to defend themselves
in a malpractice claim. If you can’t produce the documentation, then
your version of the events will be suspect.

Reputable service bureaus have quality and auditing measures in place to
ensure accurate and complete conversion of paper charts. While the
upfront costs may seem higher, the peace of mind and longer term savings
are worthy of consideration.

John Meewes, President of National Scanning. National Scanning offers secure nationwide HIPAA compliant patient chart scanning services and EMR implementation consultation. www.nationalscanning.com – Patient Chart Scanning Services (888) 211-1797

About the author

John Lynn

John Lynn

John Lynn is the Founder of the HealthcareScene.com, a network of leading Healthcare IT resources. The flagship blog, Healthcare IT Today, contains over 13,000 articles with over half of the articles written by John. These EMR and Healthcare IT related articles have been viewed over 20 million times.

John manages Healthcare IT Central, the leading career Health IT job board. He also organizes the first of its kind conference and community focused on healthcare marketing, Healthcare and IT Marketing Conference, and a healthcare IT conference, EXPO.health, focused on practical healthcare IT innovation. John is an advisor to multiple healthcare IT companies. John is highly involved in social media, and in addition to his blogs can be found on Twitter: @techguy.

8 Comments

  • “… a physician who had temporary help literally throwing charts away to create the illusion of higher productivity.”

    That one quote is about as scary an idea as the recent blowup about selling copier hard drives full of private medical information. It’s actually my biggest fear in how speedy this HIT revolution is being pushed: the desire to “prove” that “something” is being done may outweigh good, seemingly common sense practices.

    Understand, I’m not blaming HITECH for what is obviously a physician’s mistake, merely pointing out that the pressure to accomplish is being ratched up. I sincerely hope most providers and hospitals are of the “measure twice, cut once” persuasion.

  • Not sure about the argument here. A missing chart is far more likely in a paper record surely? e.g. If it is misfiled or misplaced in a pile of other charts and added to the wrong record it is essentially lost….

    I worked for a capture organization in the UK that specialized in Medical Record capture. I think that yes some capture organizations have adequate quality control measures in place, of course as you suggest some do not. However the main consideration like in any project is the preparation.

    Whoever scans the records for a practice be it, temporary workers, staff or outsourced specialist scanning companies, preparation is paramount. Someone is going to have to go through each record making sure every document in the file is relevant, requires scanning, and is in the correct order according to specific practice processes.

    You cant rely on anyone else to do this, they simply do not have the experience, skills or desire to make sure it is done correctly.

    Many practices find the ides of Bulk, or large scale capture cost prohibitive and opt to go for a “scan on demand” solution. This is a solution were the physician sees the patient in a the normal way, makes updates to the file, and sends it to be scanned as part of the patient sign out process. Then works electronically going forward.

    With this method you capture those records that are most needed (often your most frequent patients) and gradually eat the elephant rather than attempt to swallow it whole.

    In the UK for a period of time there was a reluctance to capture back file because of a lack of definable scanning standards and a fear that without them their scanned records could be deemed unacceptable…. Indeed many practices did not scan the backfile opting to work electronically from a set date and continue to store and manage files with the expectation that their investment in terms of time and staff would be come less and less over time.

    I have a couple of questions:

    1 – Are you suggesting in your last paragraph that scanning bureau should take on the liability post capture should a chart be deemed incomplete?

    2- Is there a specified retention period for the original paper before it can be destroyed?

    3 – Are there regulations around how these records have to be destroyed? ie must they be cross cut shredded or some other /secure method?

    4- Does a scanning standard exist in the US for medical records? If so perhaps you can share more information here?

    Best Regards

    Gavin

  • Gavin’s questions are valid questions that I seeking answers for; and a bit more.
    What % of Doctors require this image capture service?
    And what’s the associated approximate costs? Is it per Patient Chart?
    I understand that digitizing of paper charts, only just does that and does not do anything to value add to structured data? Is this okay with the Physicians? Or do the Physicians want to capture some of the data including demographic information, smoking status, etc., as structured data? And is this service being provided by your company?
    We at EHIconnect.com deliver SaaS EHR and will like to know the answers to some of these questions so that we can promote where desired.
    Thanks

  • Like Mr. Meewes, my company is one that offers medical record scanning services, so I strongly agree with his post. I’d just like to add a few comments in addition to what he has stated.

    The act of scanning a paper medical chart, given today’s scanners and software, is certainly not an overly difficult process. However, scanning 1 file versus scanning say 5,000, are two entirely different things, and that’s where the service bureaus offer a level of expertise that ensures this process is done correctly, thoroughly, and accurately.

    As Mr. Cooper pointed out, there are certainly offices which are capable of doing this on their own using a “scan on demand” type method. There are numerous platforms which offer offices just this capability, and when run correctly it can work. However, it’s not just the preparation which is essential, but the follow through as well, which is where things most often run off the rails.

    An office using existing staff to scan as patients visit or schedule presents the distinct possibility that the scanning will fall behind. While a plan may be in place, when things get a bit busy, scanning of the charts is one of the first thing that gets put in the “to do” pile. It doesn’t take long before things end up far enough behind that an office ends up working from both an EMR system as well as the old paper files, essentially doubling the work. The result is an office that says their EMR made things worse instead of better.

    Using temps hands over the task of ensuring proper record retention to a group of individuals with little interest in the long term. This is not to speak poorly of temporary workers, but in order for this to work there needs to be supervision and oversight. This includes setting up a quality control measures, tracking of files through the process, then cross checking loaded data vs. paper records. A service bureau offers far more than a person to push paper through a scanner. Hiring a team of temps amounts to offering nothing but that, presenting considerable risk to the practice.

    The other thing to take into account is the ability to transform space that was once used to store patient records into revenue generating space, such as an additional exam room, as soon as possible. The cost of paying a service bureau to perform in a few weeks what it may take an office 5 years or more to do has the opportunity to pay for itself within 12-18 months. So ultimately, there is financial and quality benefits to working with a service bureau to convert paper records into a digital format.

  • @ Gavin: Absolutely, paper records are far more likely to be lost than their digital counterparts.

    Thorough auditing during the scanning process leads to the discovery of many “lost” paper charts; carelessness may send perfectly good paper charts into a digital black hole, or worse.

    Each of your points could be a whole post and then some – in summary:

    To your point #1, a scanning company must be able to document their tracking and quality control processes (Medicare requires this specifically). It is less a matter of liability for lost records than it is ensuring that every record that did exist on paper is properly converted.

    Your points 2 & 4 regarding retention of original paper records – in the US, different states have different guidelines for retention, whether on paper or digital. Further complicating matters are requirements set by Medicare / Medicaid, other Federal agencies and malpractice insurers. The provider’s specialty and the age of the patient also play a role.

    Laws regarding the destruction of paper records after scanning differ from State to State, and Medicare requires that scanned images can only be used when the image will be identical to the paper original, as verified through a documented QA process.

    Any time there is any question, we always encourage our clients to obtain an opinion from outside legal counsel.

    I am curious if any definitive guidance was ever issued in the UK?

    Regarding destruction of PHI, most of the guidance is that the paper files (as well as backups of electronic files and other physical records) need to be rendered into a form so that they cannot be reconstructed. Everything we shred is cross cut, co-mingled, and baled in a NAID (National Association for Information Destruction) certified facility. Liability for breaches and agreement structures between providers and vendors could round out another whole post as well.

    @ Anthony: Conversion of paper records can be as simple as saving the scanned record as a named pdf on a CD, to, as you mentioned, data capture from the charts and importing the associated data into the EMR. Many times we work with providers to populate their EMR system with structured data from existing billing systems and supplement the billing systems data with fields extracted from the scanned chart.

    @ Tom: Great follow on points, especially relating the the difference between converting a handful of records and accurately & efficiently scanning thousands of charts.

  • We are a scanning service bureau that specializes in conversion of medical records. I can corroborate the assertions made regarding higher than anticipated conversion costs and quality issues with real world examples.

    We have had to completely re-scan a collection of patient charts that were initially scanned by a practice. There weren’t any quality control steps in place and once the practice started referencing the scanned charts, numerous errors were found including many charts with inter-mixed patient information. We were consulted to see if we could “fix” the scanned files, but the cost and effort of reviewing all the image files and comparing them to the physical charts and making corrections would have been greater than re-scanning the charts. Unfortunately the practice ended up paying for the scanning project twice due to poor internal quality control.

    We recently talked to a practice that decided to do their own chart scanning. The practice manager sheepishly admitted to us that at that time (over a year into the project) that they had spent more than three times the amount we quoted and were still in the process of scanning charts over a year later, work which we could have completed in 60-90 days.

    A professional service bureau is a “scanning factory”. They (we) utilize production level scanners that produce better quality images and have two to three times the throughput of a scanner within most practice’s budget.

    Each step of the process (document preparation, scanning, quality control, indexing, and final image release) is performed in large controlled batches by separate operators. A different person is performing the work at each step of the process which helps eliminate errors.

    Sophisticated document capture software is utilized to manage batches of images and tools are available to ensure proper separation of patient files and emulation of the structure of the existing paper charts. Existing patient data can be utilized to improve the accuracy of patient metadata and to reduce indexing costs.

    I was at a practice recently and they were scanning documents and immediately dropping them into the shred bin. I don’t think it was an act of intentional negligence, but simply putting too much faith in the system and a lack of knowledge. It was their first time ever performing a scanning project. They simply didn’t know any better.

    Practices are focused on providing quality health care and operating as efficiently as possible. Scanning isn’t something they’ve been trained to do and the process is often over-simplified by EMR vendors. The EMR providers want to avoid objections to their sale and avoid the cost and effort involved in scanning patient records. An experienced scanning vendor will have perfected the process and created a process to anticipate and eliminate potential pitfalls.

    Not all practices will benefit from scanning. Surgical clinics and other practices that are less likely to have repeat patient visits may do better to scan as needed when a patient returns. Practices like pediatrics and OB/GYN continue to see the same patients on a regular basis for a long period of time and may want/need to keep records longer.

    Practices that fall into this latter category will have a much better transition and better acceptance of the system if they convert existing records.

    Another issue that often isn’t taken into consideration when evaluating the return on investment is the cost of off-site storage. This can be tens of thousands of dollars per year for even a mid-sized practice, especially if there are frequent retrievals of records from the off-site storage vendor.

    You wouldn’t want a patient to self-diagnose with no experience or training, yet that is effectively what many practices do when they decide to do their own scanning using temporary help. They often get it wrong and end up “sicker” than when they started and needing major surgery.

  • Thank you for sharing such a useful information.iDOC is a document management service provider that offers both hosted document management and in-house solutions in Texas and Dallas as well. iDOC has more than 12 years of experience with industry-leading quality control processes and provides best-in-class document management and litigation services to all clients.

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