Stats Explained: EMR Estimations for Clinicians

EMR Scanning estimation for clinicians:

It took us a solid 90 day work out to successfully finish Patient Medical Records(PRs), SCAN READY for Electronic Medical Record conversion.

A total of 26,871(PRs){1,078,547 pages} are prepped, indexed and scanned in to electronic files as specified by EMR software team. It took ~250GB of disk space at 300PDI resolution in Black & White. A total PRs shredded were ~33,300 pounds.

As explained earlier in the blog clearly, not all the PRs have ended up in the EMR systems. Only Active Pateint Charts were uploaded but inactive PRs(old) were loaded in to a local server for quick access. This has resulted in no paper records at the clinic. All the records are at a finger click reach for Dr.Mani.

 

PDF to TIFF conversion

1.Steps to create MDI/TIFF :

To install MDI, go to the Control Panel and click on Add/Remove Programs or Uninstall a program if you are using Vista.
Next scroll down to Microsoft Office 2007 (Professional, Standard, Home, , Plus, etc) and highlight it. You should see the Change button, so click on that.



Make sure Add/Remove Features is selected and then click on Continue.



Now expand Office Tools and click on the drop down menu next to Microsoft Office Document Imaging and select Run All From My Computer.



MDI will be installed onto your computer and you’ll see a new virtual printer called “Microsoft Office Document Image Writer” in the list of printers. You can now create MDI files and view them without a problem. Enjoy!

2.Steps to Convert PDF to TIFF:

First we need to install Microsoft Office Document Imaging into your system using the procedure given above.
Open a PDF file. Click on Print to print the file.



Now you will see a print window. Select Microsoft Office Document Image Writer from the list of printers. (Click on the properties to select the default folder for the output file to be saved). Click Ok to continue



Now you will have to save the file and the save as type format is Tagged Image File(*.TIF).



(*Contributed by Rajesh)

PDF vs TIFF: Assumptions and Facts

Scanning patient charts in to PDF or TIFF formats is an important aspect to figure out before one intends to pursue EMR. Even though PDF is widely renowned document format, EMR soft ware companies prefer/decide what format best suit their interests(storage space in the network played a key role in our case). 

From our experience, even though we scanned all the patient records in to PDF files, the EMR software company decided to accept only TIFF format(at 200DPI). It should be remembered that this format glitch might unfold itself in to a mishap in EMR scanning operation. 

TIFF and PDF formats are owned by ADOBE company. Most of the scanners are compatible with PDF and TIFF formats. 

There is a problem though! 

PDF is ideal for document files (A scrolling function is often very practical). Where as, a TIFF is meant for Image files (Normally you dont see a multi-page TIFF file). Our EMR support asked for a TIFF file which can incorporate numerous pages ~ to a PDF file. 

Most of the softwares (ADOBE Pro, 3rd party converters, etc.) convert a PDF file with 10 pages in to single page - 10 TIFF files, which is cumbersome to integrate in to EMR systems. Because you need to have a standard naming convention for the files you want to upload in to your software.

We have decided to upload only Active patient charts  in to EMR system. We managed to scan 7,200 patient charts in a matter of 20 days with out causing interruption/inconvenience to the clinic. Our solution paid off finally. We used to pick up 40 boxes(each box contain 30 patient charts) each day and used to return them back the next day for clinic use. Literally we had to split out the team in to two shifts(Day & Night) pushing the scanners to work almost 24 hrs a day. These 7,200 PDF files are converted to TIFF files in 220 hrs.

I would share the PDF to TIFF format conversion procedure in a different post soon. Its a simple function which costs you nothing.

SHRED: Pick Up

Well, the day has come; for us to analyze how far we are in completing the project. We have handed over 350 regular size boxes filled with patient health information to shredding company. They seems to know what they are handling. They didn't leave a single paper behind and are decent while handling the boxes, wrapping them up in cellophane. 

I hope we are half way through in completing the project. So here is the estimate of work in terms of number of boxes:

Boxes Shred: 350 (~11,238 pounds)

     Patient Record(PR: 1992-1999) Boxes scanned: 129

    Patient Record(PR:  earlier to 1991) NOT scanned: 50

     EOB boxes scanned: 69

    EOB boxes NOT scanned: 52

Boxes yet to scan ~ 270(prepped)+150(unprepped)                               

Active Charts - Laborious Task

We have started prepping and scanning Active charts (OBGYN patients whose charts are active with visits). In order to integrate the scanned files in to EMR system, as briefed before in the blog; we are scanning a single patient record in to three files, Clinical Notes, Labs & Imaging and Miscellaneous. When you click on a folder of a patient you will be seeing three files with the above mention naming convention. As per the implementation plan, all the three files will be separately shown under respective titles when you open a patient account on EMR template. 

To show how laborious the scanning process is when it comes to EMR compatibilities, the following is an example:

For prepping and scanning a patient record for EMR compatibility, our efficient team is taking 7 minutes in total to get it done. When compared to Old record scanning which are not meant to be on EMR network, its a whole +3min extra time.

In other words, as the detail of indexing increases, so does the time. It is essential for the physicians and the clinic staff to come up with logical solution about details of indexing. As the indexing details increase, the time and costs associated are meant to raise.

EMR: TIME and its Essence

The following information (Old Patient Record scanning) provided represents personnel doing the work full time.

* Average time taken to prepare chart:   2.0 min

   (Include: Chart profiling, removing staples and folder clips)

* Average time taken to scan a patient chart (B&W):  2.0 min

   (Include: Scanning and file saving)

* Average number of patient charts prepared for scanning/day: 825

   (Include: 4 team members working approx 8hrs/day)

* Average number of prepped charts scanned/day: 660

   (Include: 2 personnel working 10hrs/day)

Observations and Foresight

Some of the interesting observations we have made during the process:

* Never use a GREEN highlighter in your clinic. Scanners might not be able

   to scan the green highlighted notes in B&W mode. Go crazy over 

   Florescent yellow, Orange and Blue.

* 70% of time taken for chart preparation is spent for removing staples. 

   Try to avoid large staples. You dont want to hear about the pain in

   removing them. Try using rubber bands, clips, binders. Most of them

   are reusable and doesn't leave any damage on papers.

The Limitations

With different resolution settings that are available in our sophisticated scanners, we are limited with the extent of advanced settings that we can use. Most of these are determined by the scanning speed, which is reduced to a significant level when you opt for color scan setting (When you are opting for a high speed color scanner ask the company about the speed of scanner in color mode, most often they say 90pages/ min which is for B&W setting only). When you know about these intricacies, no one would have bought a color scanner first of all for speed scanning. When I called the CANON support about this issue, they have blamed our 4GB, 2GHz desk top that we are using. Come on..

The second limit is when you start integrating your scanned patient health records to EMR software. Most of the EMR software networks are limited by the storage capacity they provide. Since the color settings take almost 3 times the space compared to similar DPI and B&W settings, why do you want to cramp your EMR system anyway.

EOB : Explanation of Benefits

Billing records, insurance payments, clinic fiscal spending and earnings include EOB. The clinic decided to retain EOB documents from last 7 years in electronic format. The rest are shredded.

Medical Records Retention and Access

A new revised physician's guide to medical record access and retention has been put forward by Illinois State Medical Society (click). Please refer to respective state medical society policies for more information. According to it, a general rule of thumb is to retain PRs (patient records) for 10 years under statutory of limitations. I thought their guidelines be more precise. 

All the older patient medical records that need not be retained are NOT scanned and sent for shredding. We decided to list the old medical files that are to be shredded in an EXCEL sheet so that patient details and the day of last visit be in our records for future access (Even with the State board guidelines, we decided to be more responsible with the patient record management). For documentation purpose we stretched retention policy to last 18 years giving ourselves an extra cushion. 

Following is a layout plan for record management:

  * Charts older than 18 years are shredded with out even scanning. Patient information (Name, DOB, Last day of visit) is stored before destroying the records.

  * Charts from last 4-18 years are scanned in to single PDF files. These files are stored in external hard drives for future access. 

  * Charts from last 4 years(active files) are scanned and saved in such a way that they can be uploaded in to EMR software.

The Moment

We are ahead in sorting the patient records(PRs). So I decided to start scanning PRs. We concluded that 300DPI and 24Bit color settings would yield us a decent color replica of patient clinical information. The final scanned documents are great. We are happy to have got Canon DR 9080 scanner. It handles stapled documents with out any problem (we saved quite a bit of time because of this feature). At 300DPI and 24 bit color settings the scanner was remarkably slow (takes almost double the time when compared to B&W settings).

Scanned active file integration in to EMR

[A sample test subject's EMR for explanatory purposes]

Active files(New files) are scanned and divided in to three PDF files for every patient. For ease of access, here is the division:

* Clinical Notes (Clinical visits, Clinical examinations, Surgical procedures,etc)
* Imaging and Labs (Mammograms, Ultra sound reports, Path reports, Labs, etc)
* Miscellaneous (Insurance details, consent forms, registration forms, etc)

All the above three PDF files of a patient can be viewed in EMR under "Previous records" section. All the scanned documents have a prefix 's' indicating scan.

Under the Previous records:
* Clinical notes is found in sPrev OB/GYN
* Imaging and Labs is found in sPrev Labs under Diagnostics
* Miscellaneous in sPrev Misc

Recycling: Yes

Converting approximately 15,000 files which are around 20,000 pounds of paper is definitely out of our control to shred. At present Cathy is finding quotes for private shredding services. The prices are quite overwhelming. If I heard it correct its almost 0.12$ per pound for in-house shredding facility.
Is it worth to consider self-shredding to save $? Have to weigh man power and time constraints(Not anymore). The biggest constraint in self-shredding is the personnel or office shredders which take at the max of 100 pages at a time to shred. I cant imagine doing that anymore. Finally its the commercial shredders who wins the day.

EMR vs Scanned doc Marriage

Today I had a brief talk with Steve Cotton from Allscripts Networks who is implementing their EMR networking in the hospital. After compromises we "fortunately" found pre-set tabs in the interface where we will find previous scanned documents.

It's so unbelievable how rigid the Networking companies can be. There is no chance to customize to the consumer needs. I believe in satisfying the end users but most start to work from the top and by the time the application reach users, its all Greek and BS. I have my own reservations with their user friendliness and their interface but I am all concerned with scanning logistics. After today's meet, I am little relieved to have a picture of the whole integration process.

(At such moments I appreciate some of our most friendly interfaces that I use in everyday life; Apple, Sony,etc. Kudos!)

OCR (Optical Character Recognition)

I have no idea about the OCR softwares available for reading scanned documents. We don't have absolute usage for OCR at this point because of our accurate folder naming and accurate search functions.

I believe that OCRs work effectively with typed content rather than hand written text.

DPI (Dots per inch)

Even though I promised the highest quality in scanning, when it comes to DPI setting I finally thought to go with 300DPI(B&W) for Explanation of Benefits(Bills and Patient charges) and 400DPI(Color) for patient records. We thought of test running the patient records with 300,400 and 600DPI and see manually the resolution differences with naked eye. There is going to be major difference(almost double) in file sizes at 300 and 600DPI.
(Resolution vs Storage cap)

We completed 20,000 pages(EOB) today in scanning at a rate of 5000pages/hr. All the files were stored in PDF for later viewing compatibility. When it comes to electronic copy viewing, ADOBE 9 Professional would give amazing capabilities of editing the scanned documents order, highlighting capabilities and many more.

Procedure specifics

Specific sequential steps:

1. Defining Old (vs) New charts (based on physician preferences)

2. Decide page sequencing in every chart for ease of access to hospital personnel. (Balance scanning difficulties and come out with sensible bipartisan [clinic vs third party scanning] option

in terms of time taken to sort chart pages for scanning and actual practical utility when reviewing e-charts in future). All the clinic staff

would know the defined order of patient information when they open a scanned folder of the patient.

Our preferred page profiling:

* Top strata: Clinical notes, visits, procedure notes, discharge summary
* Mid strata: Imaging and Labs
* Lower strata: Miscellaneous (Consents, registration forms, Insurance details, etc.)

3. Scan prepared (removing staples,etc) sorted charts. Decide single side/duplex scanning options. Save patient chart in an appropriate way(First-Last names/DOB) for later search .

4. For a fast Search-Catch, only New charts are scanned in to different sections(Clinical visits, Labs, Imaging, etc) and saved as several files in a patient folder. By this process, users were able to retrieve information in time efficient manner. All the old chart pages

were sorted in order but scanned to a single file (with pre-determined order, nursing staff were able to scroll through the file more easily).

5. Integration of New charts/Active charts to EMR software.

6. An approximate 1500GB hard drive back up provision for all Old & New charts.

The purpose of doing this time consuming and labor intensive process is to create an ACTUAL e-file(soft copy) which is as close to original file (No page left behind) for all future needs and litigation. Physician's knowledge of accessing patients entire file at his/her fingertips is truly

a remarkable achievement in our opinion. There is a greater scope to completely eliminate paper charts with out much hesitation, conserve storage space, storage retrieval costs and clerical personnel.

We are projecting that our man-$$ investment would soon be rewarded with in 3-5 years since our storage costs itself are close to 10K annually.

Hardware; Up and Running

Canon DR 9080: 2

Fujifilm

Three HP desktops of 4GB RAM

Two 500GB Lacie external hard drives rugged

Two 500GB Lacie hard drives

Our own reasons for EMR

1. Convert all the paper files to electronic copies.(See less paper around)

2. Save $$ for storage expenses. (We were paying by square foot)

3. Save on file retrieval costs from storage facility.

4. SAVE PAPER. Going Green on chart maintenance.

(Its going to be a statistic when we give the final numbers)

5. Accessing patient charts out of clinic.(Be in Hawai or Dubai)

Defining Old Files

Based on Obstertric(18yrs) and Gynecological(2 yrs) case liabilities, we concluded that as of 2009, clinical charts of 1991 and before are set for private shredding under hospital personnel supervision.

[Fun to keep track of number of cartons of patient charts each person completes][Explanation of the order of pages in a patient chart. A simple effective way to sort patient file. Its the vital basis when you scroll down a PDF doc. You could sense the location of a page as you scroll down a whole PDF file.]

Old Files: 2005 and before

New Files: 2006 and further

Resources in Planning

1. Dr.Mani Akkineni

2. Dr.Grievers EMR experiences

The Project

Obstetrics and Gynecology Clinic

Chicago; IL

Total charts for Scanning: ~15,000

Clinical Practise: 30 year old

EMR Software: All Scripts Company

EMR Going Live: March 2009

Whats our schedule?

We intend to work for 7-8 hrs daily completing 4% of work load everyday. Usually we start as soon as we finish our breakfast. By mid noon we try to finish our half day work with out many interruptions. Most often we will have lunch at the work place not wasting time to go out or to cook.

We are loving Priya food from Shaumburg.

Team behind

(Ram on top: fast and furious as usual, I had to call him 4MB RAM.)
(Saurab: By the end of the day he refuels with beer)
We are at present a team of five doing the whole process of scanning. Four devoted entirely to scanning and I supervising the process.

Today we watched "Arundhathi" at break. I was happy with today's sorting of patient records for scanning. Its still day 4 since we ordered the CANON D-9080 scanners(2), waiting for them anxiously.

We are revising our final delivery date. I expect it to be late March.