Medical records or health records contained in paper documents and file folders, that constitute patient chart information, can be found in about 60% of general practice/primary care clinics and specialist health care facilities in North America. The drive to replace them by systems that electronically store this information, making information easy to retrieve and transmit has been going on for many years. The accuracy and the flexibility of electronically stored information cannot be matched by paper documents. These paper documents that mainly contain patient chart information are often referred to as legacy data.
The purpose of implementation of an EMR system was never to work towards a paperless office. Some form of paper documentation will persists and used for the foreseeable future however, the bulk of information for future patient charts can be captured in electronic medical record and stored in a database. The question is, what do we do with the existing wall to wall paper based patient charts?
In discussing this issue with many healthcare facilities we have observed the following approaches being used:
a) Ignore all previous paper charts and enter new chart information directly into the recently acquired EMR. If information from the legacy source is required, that particular chart is pulled and offered to the healthcare provider.
b) Following the implementation of an EMR system, as each existing patient returns to the clinic, his/her chart is scanned and the resulting documents are imported into the system and associated with a newly created demographic record. New patient records are entered directly into the EMR.
Proposed Strategy for Legacy Data
The entire operation involves pre-processing of each patient folder and then scanning the contents into an electronic medium such as a DVD as illustrated above or a USB flash drive. Pre-processing requires sorting of the folder's document into sub-folders such a encounter notes, diagnostic images, laboratory reports and correspondence (referral letters) and specialists reports. All this would also require
de-stapling and sorting the document in chronological order. It is estimated that one worker could pre-process more than 4 patient folders per hour.
After the pre-processing task is complete, the actual scanning operation starts.