A
successful transition from paper-based charts to electronic health records
(EHRs) in the physician practice or clinic requires careful coordination of
many moving parts. A myriad of challenging and complex decisions must be made,
ranging from selection and implementation to training and maintenance.
Failure
to adequately evaluate the clinical workflows and information needs associated
with providing care and a lack of planning during and after go-live will result
in a fall back to paper, thereby jeopardizing the success of the EHR adoption.
This
practice brief outlines the considerations and decisions that must be made for
an effective migration from paper to EHRs within a physician practice or
clinic. It also provides recommendations about what to do with historical
patient information contained in the paper records that exist at the time of
the changeover.
Decisions,
Decisions
Physician
practices and clinics must consider the following questions when transitioning
to EHRs:
·
Which
historical patient information should be available for patient visits during
and after the transition?
·
What
are the best methods of converting this information to the EHR?
·
What
is the best way to ensure that the converted data and information is of sufficient
quality?
·
How
long should the paper record be available after the conversion?
·
How
long do paper records need to be kept after the transition to the EHR?
·
What
is the role of printing and should it be allowed during the transition?
·
There
are no one-size-fits-all answers to these questions. However, they must be
considered and will largely be driven by two factors: the types of medical
specialties and users in the practice and the information management resources
available to the practice.
Destroying the Converted Paper-based
Record
Once a paper record has been
converted to electronic media, it may be destroyed. However, there are no set
standards as to how long the converted records should be maintained. The
retention period for electronic records depends on the confidence and trust
users have in the converted data.
Practices should have a plan in
place to destroy the paper-based records in a reasonable timeframe. Once users
are confident that the data conversion was successful, it is safe to destroy
all paper-based information that has been converted.
Practices should review state laws
to determine if retention of patient information that has been converted from
paper to another media is addressed. Once decided, the destruction plan must be
clearly communicated throughout the organization.
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