Paper records were the standard in healthcare for a long time. But things have changed. Thanks to the HITECH Act, healthcare organizations have or are making the move from paper to electronic records, with as many as 80 percent of hospitals adopting a basic Electronic Health Record (EHR), or a digital version of the paper medical chart traditionally used to document patient and resident care.
And there is a good reason for this. EHRs process and integrate a wide variety of information, such as demographics, medical history, medications, immunizations, laboratory test results, radiology images, and billing information. An EHR is a vast collection of electronic health information about patients or residents, which can be shared across organizations.
EHR is one form of an electronic record and is not to be confused with EMR, which is a record of a patient’s or resident’s clinical information maintained within a single organization. Also, unlike EHR data, EMR data is not shared between organizations. Here we will discuss both EHRs and EMRs, what the transition to electronic records looks like, and how to successfully do so.
EMR Conversion: Migrating Data to Electronic Records
Migrating data from paper to electronic records can be a complex and daunting task. However, when done right, the process appears seamless to nurses, residents, and other long term care staff members. The term “EMR conversion” describes the process of migrating all patient data from paper files or legacy medical records to a single enterprise-wide electronic medical record (EMR) system. To ensure successful EMR data conversion when moving from paper to electronic records, leaders should do the following:
- Develop a communication plan: Informing all stakeholders—including staff, residents, and families—about the EMR conversion process as it happens is essential. This will help ensure that everyone is on the same page and aware of the changes that will be taking place.
- Determine the data that will be converted: Not all data needs to be entered into the new system. So when deciding what data should be transferred into a long term care EHR, a long term care administrator should consider what is most important for resident care and population health management.
- Determine the timeline for conversion of different data types: Some data, like paper medications, can be converted relatively quickly. However, other data, like paper resident care plans, may take longer to convert. Therefore, creating a schedule for conversion will help ensure that all vital records and notes are migrated on time so that providers and staff never have to dig through archives to find valuable resident data critical to clinical decision-making.
- Allocate power users: Before going live, identify staff members who will be responsible for singing the praises of the new system, helping train the rest of your staff, and being onsite to troubleshoot when necessary. These power users will help ensure a smooth EMR implementation and conversion process, as they fully understand the paper to electronic records transition process and how the nursing home management software works.
- Start EMR and EHR training: All staff members should receive training on the new system prior to going live. This will help ensure that everyone is familiar with the new platform and knows how to use it effectively. An example of a long term care EHR training resource is LevelUp, which is available at no charge at all. These training modules are free for all long term care staff and can prove to be helpful, especially when transitioning from paper to electronic records.
- Evaluate training effectiveness: It is crucial to train your staff on how to use the new EHR system and evaluate their understanding of and confidence using the care plan software before and after conversion. This can be done by setting up simulations or tests with your EHR vendor. By doing so, a long term care leader can identify any areas of confusion or lack of confidence amongst staff and provide additional training as needed. This will ensure that everyone using the new system is confident and able to input and access data accurately.
Contact us here if you’re ready to transition from paper to the most user-friendly electronic health records on the market.
7 Steps to a Successful Transition From Paper to Electronic Health Records
The transition from paper to electronic health records can be a daunting task. Data quality, cost, and staff training are all major concerns. Still, they are a small price to pay for the benefits that the transition from paper to electronic records offer, such as improved patient care, increased efficiency, and better population health management. Below are a few tips to help make moving from paper to electronic records as smooth as possible.
1. Consider the Available EHR Vendors
Each of the EHR vendors currently operating will offer different features and services. What is important is that your administrator considers the particular needs (and limitations) of your organization in choosing from among them.
There are five crucial steps an administrator must take to determine the best EHR for their facility and negotiate a fair contract:
- Research the EHR vendor to find out the markets they serve, the features their software offers, and any online complaints from former customers
- Request the pricing and compare it with the facility’s budget
- Schedule demos with a sales rep while agreeing on the pricing of the demo
- Send requests for proposals (RFPs) detailing the software features the facility is interested in
- Test out the EHR when the demo becomes available, ensuring nurses and other crucial staff have a go at it to determine its compatibility with the facility.
2. Look at the Requirements List of Your Facility
A requirements list is a tabular representation of requirements and a tool for searching and evaluating solutions that fulfill requirements. For long term care facilities, nurses and other relevant staff will create a requirements list, and it will typically contain what they require from their new long term care software. This means that the EHR used when moving from paper to electronic records should still contain some of the benefits of paper records that nurses and other staff members are accustomed to while adding additional benefits.
3. Start Planning
The paper to electronic records conversion process can often take anything from several months to a year to complete. This is why it is essential to start planning the paper to electronic records transition as soon as possible.
This means that administrators should create adoption timelines as well as clearly defined roles and responsibilities to determine who does what during the transition from paper to electronic records. Furthermore, it is essential to involve all staff members in the paper to electronic records conversion process and ensure that they are kept up-to-date with the latest developments.
4. Start Digitizing the Paper Records Before Adding Them to the EHR
Digitization can be done by scanning or photocopying the paper records and then uploading them into the EHR system. This process can often be time-consuming, so it is important to start digitizing paper records well in advance when they need to be added to the EHR system.
The most user-friendly EHRs include eDocument modules as part of the software system. eDocuments offer the following advantages:
- Multiple users can access the same resident file simultaneously
- Files can be linked to progress notes, care plan interactions, and physician orders
- Resident information can be easily imported into the system at first contact
During the digitization process, an administrator should never forget to consider the laws and regulations governing digital and paper medical records and the time needed to digitize the paper records.
5. Adjust Workflows
Paper and electronic records are two very different mediums that require different workflows, as paper records are often filed in paper charting systems, while electronic records are stored in cloud databases. Therefore, one should adjust the workflows to be compatible with the new medium. An administrator can do this by creating new policies and procedures and training staff members on how to use the new workflows.
6. Destroy Paper Records
Once paper records have been digitized and added to the EHR system, the facility’s staff should destroy them. This is because paper records can be a security risk if lost or stolen. Destroying paper records can be done by shredding or burning them.
Facilities must be sure to first check the laws and regulations governing paper records before destroying any paper records. It is also advisable for a long term care facility to keep an electronic record of what and when the paper records were destroyed.
7. Maintain Continuous Training
Paper to electronic records conversion can be a significant change for most healthcare facilities, which is why it is essential to maintain continuous training. This is because nurses need to know how to use the new EHR system and adjust their workflows accordingly.
Maintaining continuous training can be done by providing staff members with training materials, such as manuals, how-to guides, and video tutorials. Furthermore, long term care staff should be provided with ongoing support, allowing them to ask questions and get help when needed. Finally, it is also essential to conduct regular training sessions so that staff members can keep up-to-date with the latest software changes in their EHR.
What to Keep in Mind When Transitioning From Paper to Electronic Records
When considering transitioning from paper to electronic records, long term care facilities should keep in mind the following:
- The requirement of making patient and resident information readily available during visits
- The length of time to keep the paper records after transitioning from paper to electronic records
- The role that printing plays and whether or not it will be kept after the transition
- The best EHR or EMR conversion methods for data quality
It is also worth noting that, as the popularity of EHRs increases, the legal and compliance requirements have also become more stringent on account of the data capabilities of nursing home software. An example of a stricter form of regulation is the Health Insurance Portability and Accountability Act (HIPAA), which safeguards medical information, data privacy, and security provisions.
The HIPAA Security Rule requires long term care facilities to put in place physical, technical, and administrative safeguards to protect the confidentiality, integrity, and availability of electronic health information.
The Centers for Medicare & Medicaid Services (CMS) has also released a final rule that updates the requirements for participation (Conditions of Participation, or CoPs) in the Medicare and Medicaid programs.
Making the switch from paper to electronic records can be challenging for any healthcare facility. To ensure a successful transition, health care facilities must start the planning process early, digitize paper records before adding them to the EHR system, adjust workflows, destroy paper records, and maintain continuous training. But, of course, all of these would be pointless without first choosing the best long term care software EHR for your needs.
Leaders would be wise to select an EHR vendor that lives by the 3Cs: customization, customer care, and commitment to the industry. Doing so will give them peace of mind that they have made a decision that is in the best long-term interests of their organization.