# Paper to EMR Transition

## Step 1: Populate an electronic index of patients

Most doctors possess some kind of electronic index of their patients, commonly from billing or scheduling systems, and from which they will try to at least "seed" their EMR with a list of patients to whom care had been provided. Minimum "ported" information may be the patients' names, dates of birth, sex (gender), possibly their health insurance number(s), and possibly additional names (aliases) if these were supported in the source system. Possibly the dates of first service and last service (but note GNUmed does not at the present time hold any appointment information.)

The above depends on being able to get this information out of the old system, without having to pay ridiculous charges, and getting it in a form that will go into the new EMR.

One option by which to transfer and import the data would be in a "batch" mode. Th alternative would be on an as-needed basis if where single patients' data can, on demand, be exported from its origin and then imported into GNUmed. It is possible to define for GNUmed an importer template to understand the form and content of the external data. GNUmed also offers a "slave mode" if it is possible to get the source system to work with GNUmed. This is especially desirable if doctors are already using a billing or scheduling system that they may like to continue to use.

For most practices, proceeding with Step 1 should be co-ordinated with your plan to use the system for something more than just patient demographics. Typical minimum additional functionalities would be the tracking and maintaining of

- problem lists
- allergies, immunizations and medications
- incoming results (test data, reports)

As at February 2010, GNUmed manages problem lists and SOAP notes; provides the ability to record allergies; the input and printing of simple medication lists; the import and signing of digital documents; and manually inputting and signing test results. Batch importing of digital (lab) results has been specced out and is being gradually brought to fruition.

## Step 2: Stop adding new paper to the old paper chart

Before you even begin to worry about converting existing charts, you must first figure out how to stop adding paper to your charts. This means that you must develop a reliable system to intercept all incoming and internally-generated paper and to redirect and/or translate it and manage it inside a safe, secure and standards-compliant "digitized / digital documents workflow".

Do make sure you know your national legal and professional regulatory requirements for records retention and archiving before you spend time and effort converting, importing and archiving documents. The well-known Portable Document Format (PDF) is not an image format, and could be judged inadmissible in the event of disputes over records of care. In some jurisdictions it may be necessary to preserve your images as TIFF files, despite what may look like redundancy if you should prefer to import PDF versions into the patient record. Do not lightly dismiss this consideration.

Approaches for various sources of new paper are offered:

Source | Solutions | See
--- | --- | ---
all sources | petition to be sent digital streams or files | regional advocates
incoming faxes | efax services, or a fax server | Fax Integration
online data | download or Save as or "Print" to a digital file | web search: "Print to PDF"
unavoidable paper (mailed or hand-delivered by patients or via doctors' bags) | image scan ± optically recognize | Document Imaging

Keep a clear record of the date(s) on which you implemented the above changes in your praxis, and make sure all of your staff and doctors are aware. This will save a lot of trouble looking for information in the wrong places.

Congratulations! Your non-granular patient information is now GNUmed-attachable via the GmManualDocumentImporter plugin. All that remains are your now "frozen" archival paper charts…

## Step 3: Choose how much archival paper to import

How much historical paper is worth scanning from each chart? One option would be to have the secretaries transcribe the inside cover "summary" information, where summaries already existed, from which the problem lists could be generated. Another would be to scan (e.g. into pdf) just the summary, or the entire chart, or anything in between the two.

However, unless all of the entirety of a patient's chart would be scanned, it will need to be retained somewhere and accessed as needed in conjunction with the electronically-maintained information, under a so-called "hybrid" model.

Scanning and filing patients' entire paper medical charts is a lot of work, and typically non cost-recoverable, except from private payers. The value proposition may be better at retirement compared to physical storage in trust with management fees. Patients have been offered the option to pay a fee to have their charts scanned, typical runs entailing 30 - 60 minutes' work for which (e.g.) students could be hired. A charge to the patient can in some jurisdictions be levied for "electronic archiving, pdf rendering and encrypted USB key preparation".

Tips:

- some doctors who move to an EMR use the first subsequent visit of each pre-existing patient to populate the EMR with a problem list and to identify "key pages" for scanning.
- some suggest that the subset of pages that had been scanned be kept in a separate section at the front of each paper chart, in order to avoid later re-scanning what had already been scanned.

The transition can take between 6 months and two years. A lot of your processes (and those of the office staff) will need to be re-engineered.