Scanning Documents

Before going live on a new EHR, there must be a workflow in place to convert paper data into an electronic form. There are many different processes to completing this daunting task, but they all center around scanning of the paper record.

Methods

The methods that will be considered are:

• Scanning every single current chart in the office before going live.
• Scanning every patient's complete chart before the next visit after the go-live date.
• Scanning only critical elements of a patient's chart after the first visit after physician review and retention of the chart in the office for future visits as needed.

Scanning every single current chart

Charts not used in 3 years can be pulled and archived as has been done previously. The remainder of the charts will be systematically scanned and then archived. Once every single element in the chart is present in the EHR and legally retrievable, the paper chart is no longer needed in the office workflow and can be marked for destruction.

Scanning every patient's complete chart before next visit

This would be expected to significantly reduce the number of charts that would need to be scanned, however every chart that is not scanned will need to remain as a paper archive. This method would integrate the scanning into day to day office workflow, with significant time resources needed to complete the scanning task.

Benefits:	Drawbacks:
The task will be completed before the go-live and there will remain no dependency on the paper chart.	Waiting for scanning to be completed would delay the implementation of the EHR
If a service is hired for the task, no additional office based labor would be needed. The scanning would be done offsite, minimizing daily workflow interruptions.	This method will be quite expensive.
Alleviates the need for all charts used after the go-live to be retained in archive for the requisite number of years. This may save storage costs in the future.	Specific data from a large chart saved as opaque scanned data is difficult to access in the EHR as document images.

Benefits:	Drawbacks:
Compared with the previous method, this method should involve less scanning	The process will be ongoing for at least a year, perhaps longer.
After the initial post-implementation visit, it is not necessary to handle the paper chart again.	Some very old and unnecessary data will be scanned needlessly.
Process is integrated into workflow, alleviating the need to do all the work before going live. There will be fewer delays to implementation.	Daily, a significant amount of scanning will need to be done. This will taper off, but it is expected that extra labor will be necessary to prepare for the day's appointments.

Scanning critical elements of the patient's chart after the next visit

This method would further reduce the amount of scanning that needs to be done. After the first visit after go-live, the physician reviews the entire chart, flagging essential elements for scanning. The chart will then be tagged as reviewed and scanned. It will, however, prolong the period of time dependent on paper charts.

Benefits:	Drawbacks:
This will require the least amount of paper manipulation and scanning.	Dependency on paper charts will be prolonged. For months or perhaps longer parts of the old workflow with paper charts must be maintained.
The task can be integrated into the daily office workflow.	More labor will be needed from the current staff. The extra scanning volume may not warrant a temporary employee. The office assistant will need to be involved with the scanning of flagged portions of the chart, and the physician will need to take extra time to flag the items required.
Archiving process will not change greatly.	The archive period will be longer, essentially 10 years from the go-live date.
With less superfluous opaque data in the record, quick retrieval of scans may be easier.	Data may be missed in the scan and require retrieval of the paper chart.

Comparison

Method	Time	Cost	Labor	Access	Retrieval	Archiving
Pre-scan everything	+	+	+	++	+	+++
Scan chart before visit	+++	++	++	+++	+	+++
Scan parts after visit	++	+++	+++	+	+	+

Resources

Scanner

The scanning equipment needed will depend on how much scanning will be done. Some options, from lowest estimated cost, are:

• Small office desktop scanner, purchased
• Medium sized desktop scanner, leased
• Business all-in-one with a small additional desktop scanner, leased

Purchase

A scanner for purchase would run about $500-1000. This would be an excellent choice if partial charts only would be scanned. It also may work if entire charts are scanned as patients are seen. Many of these scanners have a daily volume from 3000-6000 scans.

Considerations:

• Purchase will provide equipment ownership, but as technology changes the item could become outdated.
• If the scanner is owned, the onus will be on the clinic to use resources to setup, maintain, and repair or replace the scanner.
• These models are not designed to run all day long in a systematic scan process if the entire collection of charts will be scanned.

Short term lease

A larger variety of scanners can be made affordable by doing a month to month lease program. Support is generally telephone only with setup to be done by the clinic. Problematic equipment usually can be sent back to the vendor for replacement at no cost. There would also be flexibility in changing the scanner for a different model if scanning does not go smoothly. Monthly rent would run about $250.

Considerations:

• The optimal scanner for each stage in the scanning process could be acquired.
• No concern with repair costs.
• The price of rental could soon overtake the cost of ownership.
• Care must be taken to negotiate the exact terms of the contract.

Long term lease and support

The complete business solution is a contract with an office equipment vendor. A larger all-in-one unit including fax, copy, and scan can be leased for the long term. The company should do a workflow analysis and determine the appropriate unit for the office. Equipment can be switched out if needed, and there is onsite setup and support.

Considerations:

• Complete, no worry solution promised by the vendor
• Lease terms tend to be quite long (3-5 years), and the equipment might be overkill after the transition is ending
• Control of the office copying, scanning, and faxing operation is given to the vendor.

Comparison

Scanner Type	Cost	Speed	Capacity	Support	Failure Expense
Retail	+++	+	+	+	+
Short lease	++	+	++	++	++
Business station	+	+++	+++	+++	+++

Discussion

The bulk of the time in an implementation will be spent converting old paper records to electronic form. One thing to remember is that anything scanned into the chart will be "opaque data" that will not be searchable within the documents. If many pages are scanned into the OpenEMR system, the clinician will need to search through the document files manually to get to the information needed for an encounter. While it is tempting to consolidate entire charts into OpenEMR, the resulting information may be difficult to view on the fly. The most important pieces of past medical history to retain would be very recent labs and imaging as well as older, expensive, and rarely administered tests such as polysomnograms.