Electronic Medical Records (EMR) – Is It All There?
In the summer of 2008, I was fortunate to travel throughout the Midwest and the east coast. My job was to audit charts. I audited both paper and electronic medical charts, and listened and spoke with physicians and nurses. Being a nurse who likes to analyze what works, what doesn’t work and why or why not, I learned a lot about electronic medical records.
Have people walked behind the scenes in a medical record’s office, where the paper charts are stacked from the floor to the ceiling,in what appears to be alphabetical order, or alphabetical disorder? Doctors often prefer it to the electronic health record systems that are merging with the paper records.
With good reason, I spoke to a doctor in a clinic in Kansas City, who quoted, "I refuse to have electronic medical records. I’m afraid something will be missed if we change over, and try to scan all the documents." Some of his charts were over 3 inches wide. They were very thorough, and he was proud of his documentation. In the same office I spoke with the nurse who was charting on paper, and she had a very interesting aspect, "Besides missing something by not scanning the document, we might forget to put a blood pressure or temperature in the computer. Not all patient information is written in the chart, and that is scary. It is almost like double charting."
At a near-by hospital, the charting was done almost completely in the computer. The charts were audited in the computer, as well. Some of the documents stored in the computer were poorly scanned. And some of the documents should have been in the computer but were never scanned in the first place. This is exactly what the doctor was talking about.
Scanning The Document
There is a way to make sure all the documents in a paper chart are clearly scanned, and all the documents end up where they need to be. Nothing has to be skipped. This is how to make sure everything is scanned.
Usually, there are one or two medical records clerks that are in charge of changing to EMR. A physician overlooks the project, and maybe the medical records clerks get help. I’ve seen it many times, walking into a clinic that is in the process of changing over to electronic charting, and the EMR clerk becomes interrupted, and looses her place while scanning. Something is bound to be lost. Here’s how to fix it. It is a very simple solution.
The scanners I’m suggesting are scanners that nurses like myself use to audit charts. They are the size of a folded umbrella. They are mobile, and attach to a computer through a USB port. They only require simple maintenance. I saw nurses in Flushing, New York doing this. It was smart, and it worked. It was a small clinic, by the next week, the paper charts were stored alphabetically, with the nurses and staff having access to both the paper charts and the EMR.
If a medical records department was equipped with three mobile scanners and they asked for help from three extra staff during the facility’s change-over, the scanning could be done in an assembly line. Each pair would take one chart. While one removes a page, the other scans a page, and places it back into the chart. Keeping the paper charts are inevitable protection, both for the facility and for regulations.
The Confusion with Electronic Health Records
Not all is negative with Electronic Medical Records. Computers are faster than humans. If a document is needed in an emergency, the last name is typed in by the unit secretary, and the page is selected, and printed. The common systems used in this country are by the Cerner Corporation. Cerner stands by their product and has a good reputation. Facilities that start with computerized systems do not need to do any changing. Computer screens are HIPPA compliant, in that, they can be turned to face a nurse, so that the name is not seen by a curious family member.
On medcarts and at nurses station, new facilities are using tablet PC’s to record Meds and vital signs. As long as everyone in the facility is compliant, and does the same thing, this system works well. The charts are still in paper form, because the tablet PC cannot handle the amount of information stored in charts.
Nurses and physicians can be trained, and facilities can find areas to store the paper charts, or use both methods. If both methods are used, the staff must be very meticulous at documenting everything where it belongs. Switching over to EMR does not have to be confusing. If a loved one is living at a facility that has both paper and electronic charting it is up to the family member to remind the staff to make sure everything goes into the computer. If the whole system works together as a team, computers in the clinics and nursing homes will be successful.