The electronic storage of medical records - A higher account

An Electronic Document Management system for the storage of medical records is held to much higher account, in relation to its performance expectation, than its original paper user experience.

Firstly, it's not the same as paper so the sensory and tactile ergonomics of a paper medical record are replaced by a screen and some choices that a user must make to find what they are looking for.

This first point would be relatively straight forward if it wasn't for the fact that the standard of indexation (the ability to find the documents and the expectation of where they should be within the EMR structure) relies heavily on some extremely important preconditions:

• The condition of the record, how well it has been physically treated. Are document pages torn? Are 4th generation poor quality photocopies used for certain forms ?

• The filing quality and order of filing of documents. Has the Trust filing policy been applied? Are documents placed behind the correct Tab divider? Are any loose forms or sheets filed appropriately in the record ?

• Is the volume numbered and identified ?

Achieving best practice in clinical records management relies on a dedication from all staff with adherence to standard operating procedures (SOP) and guidelines, but despite every Trust's commitments and best efforts the performance of these tasks can result in unconformity.

After all, it is the treatment of the patient that takes priority; the daily resource pressures of our modern NHS can mean the structure of the medical record may not always be constantly maintained. Thus varying degrees of non-conformance exist with resultant filing quality across the NHS as a whole. We have yet to meet clinicians who tell us their Trust's paper medical records are of perfect and exemplar condition in this respect.

Attuned as they are to this reality, clinical staff will also grant a degree of tolerance to the standard of filing within a record, but not without consequences.

A common example of this would be clinician A filing the last letter from the patient's GP behind a test result within the "Results and Investigations" tab, rather than filing in chronological date order within the "Correspondence" tab where it belongs.

Clinician B is looking for that same letter in the record Correspondence tab but can't find it, eventually discovering it in the Results tab having taken 3 minutes longer than planned thumbing through the volume. Yet at this point clinician B is happy to accept that clinician A deviated from the filing policy possibly 'for their own good reason' or 'for convenience' and doesn't re-file the letter. After all, they are now delayed by 3 minutes by the search and the patient is now waiting for their appointment; they don't have time to tidy up the record.

When Trusts plan programmes of change and embark on EMR deployments they will consider their options and decide how much time and effort to invest in improving the 'legacy' records they hold at the point of digitizing them.

Examples of such options are to scan them as they are and structure them as larger sectioned archive files; or invest in combinations of people and technology to render the scanned record in a much more granular way; to make it searchable and extract structured metadata from the paper scanned images, for the EMR to index against.

Physically restructuring all records and correctly filing all documents prior to scanning is a labour intensive, manual process which may not yield the best return on investment. For example, part of the file scanning preparation process can include the insertion of barcoded sheets in front of file sections and individual documents enabling file metadata to be created as the scanner reads these barcodes. This approach can lengthen the scanning time and the scanning cost overall.

Use of tools to digitally read, recognise and classify the imaged legacy file documents (post scanning) is now beginning to increase. Use of optical character recognition tools ( OCR) on images down stream of scanning is also growing.

Such tools will generate structured metadata from unstructured pages of scanned text meaning the documents can be searched and information mined and indexed within an EMR to a location where users expect to find them. 

Whilst this approach is not the technological panacea to cure all ills, it does have great merit and is fast replacing the labour intensive, manual approaches to the 'indexing problem' that many encounter.

Fortrus has implemented our 'Unity' solution in many NHS Trusts and taken a number of unique approaches using technology to best fit the requirement, whilst ensuring at all times that users can find documents easily and quickly. 

The requirements will often depend on the Trust business case and budget for scanning along with an appetite to invest in OCR technology solutions.

CCIOs will deliberate with their clinical colleagues over the cost vs benefit arguments from the resulting output:

• How much do we expect to invest in order to produce a navigable, indexed legacy record for our EMR?
• Do we need much granularity at all? How often are the legacy case notes clinically examined to such a great extent and by whom?
• Must we identify every Nursing form and Operation Note individually for the entire 10 year history of the multi volume record and what costs are involved in achieving that for fast retrieval in the EMR?
• Is the investment in deep level indexing the entire legacy case worth the clinical pay off?

EMRs are always held to higher account. In our experience the clinical user expectations for an EMR will always be high; much higher than the user experience and user expectations for the original paper case note and regardless of the general condition of documents and filing within the original case note.

Fortrus consultants can help the organisation assess its clinical needs for EMR, ensuring the organisation yields the highest return on investment. 

We work with technology partners to transform healthcare and to date have delivered some of the largest published ROI results from such projects.

For Further information please contact:

Leigh Baillie

Chief Marketing Officer

Fortrus Ltd

Leigh.Baillie@Fortrus.com

+44 7894 517828

www.Fortrus.com