Scanning or entering reports into an EMR

How do you handle the process of entering reports into your EMR system? Unfortunately we still live very much in a paper world and as a result, there is a huge amount of paper that flows continuously into a physician's office. This data has to be inputted into the EMR system in some form in order to create a comprehensive patient record.

My experience has been to review all incoming reports and select those that I want to have scanned into the EMR. These are then scanned using a high speed scanner as Adobe .pdf documents. This allows for relatively small files which is economical from a storage perspective. I estimate that I am able to reduce the amount of unnecessary scanning by reviewing the documents first. Some practices may scan all documents into their EMR systems. Others may scan and convert the documents into searchable text using OCR (Optical Character Recognition) software.

To share your experiences, click on the 'Comments' link below.

Comments

[Roger Hamilton]

Thank you for starting this topic.
I scan all (well 99%) of the documents (50pgs/day)that 'arrive' in my office , as PDF .Some comments
1. A high end scanner is a must.(about 1000$) for paper handling and speed.
2. I think storage is 'unlimited' and that scanning is a viable option, althought backup is the real crunch.
3. I use the OCR text to 'prefile' the document. This is generally very accurate and a hugh time saver. In this instance the patient demographics or identifier are 'read' from the document and the user (staff) are prompted to file,
IE CONSULT NOTE ON JOHN DOE
DATE 13-feb-04
then if this is confirmed it is filed in pts chart for easy access.
Lab values are also read and stored from the OCR all with operator confirmation etc.
This works well for the random office phone calls regarding 'is my xxx back'.
There will be paper and documents arriving for along time in our offices..
Roger

[Leo Wong]

Which "high end" scanners have physicians worked with ?

I am looking to establish a EMR office in the next six months. Two possible scanners we have looked at, which have a reasonable combination of features vs. price are:

Canon DR2080C (Amazon.com USD 700)

HP 8250 (in various computer stores in B.C. listed at $1200)

Important features would probably include scanning into PDF, sheet feeder, scan speed (? at least 15 ppm), ease of use (the MOA is likely the person doing the scanning 99% of the time)

[Alan Brookstone]

Leo, I have been using an HP 7450 scanner with document feeder for the past two years. It is a 2400 dpi scanner compared to the 8250 which has much higher resolution.

Overall, the 7450 has been quite adequate. I have been disappointed with the document feeder which tends to skew the scanned documents sometimes and have also had problems feeding some of the thinner paper (e.g. lab results) which have tended to jam the scanner. One great feature is the direct to .pdf scan feature. In this regard, HP has really got it right. The documents are scanned automatically into multi-page low res .pdf files with the average being 80KB to 150KB. As a result, I have been able to easily scan thousands of the documents over the past two years with no concerns about storage.

The two key features you want to look for are problems with the document feeder (do some research on the Internet on some of the opinion sites - e.g. epinions.com or cnet.com) and the ability to scan into low res multi-page .pdf files.

I have not had any experience with the Canon scanner.

Also, go high-end rather than low-end for a professional level scanner. The time your staff will save with high speed scans will pay back in buckets.

[DSeguin]

I use Healthscreen EMR. I scan everything with a HP low end scanner, USB 2 connection, and it is SLOW. I do not understand the concept of multiple feed scanners, or pre-filing. I have to enter the patient's record, find the "Consultations" tab, enter the details of the consult (date, specialist), and then scan in the document. The scans are .tif, and use a lot of space.

If I buy a high end scanner, will that come with the .pdf software I require, or do I have to pay for an Adobe licence as well? I understand that this will save storage space, but how does a document feeder help me? Is "pre-filing" a term for my stamping a document to tell my staff where to locate it in the EMR? Is OCR of any real benefit: the one I tried to use (2003)was so slow and full of mistakes on different fonts as to be migrainously painful?!

[Alan Brookstone]

The benefits of multiple-feed scanners are significant. The automatic document feeder allows the user to feed a 10 page report into the scanner and with one touch of a button, scan all 10 pages without the hassle of inserting pages individually. The HP 7450 scanner that I have been using (without any custom setup) allowed me to scan directly to .pdf format. I am sure most high end scanners will do the same. Speed per page is roughly 5-7 seconds.

I would try and avoid scanning to .tif format. This creates huge files as you have mentioned in your comments. It may mean upgrading to a higher end scanner.

I have not used the OCR capability in my scanner for documents, as I store them as .pdf (which are basically image files). The advantage of OCR is the ability to search the text at a later time, however the risk is that there may be an error in the OCR (despite the accuracy) and this them becomes part of the permanent patient record.

[dseguin]

I posed the .pdf vs .tif question to my software provider. Their comments porvide an interesting perspective to this question.

"OCR is not accurate enough. We have intimate knowledge of clinics using this and it is very time consuming because the user MUST check the OCR and correction is often necessary. Corrections, and the lack thereof, render this method error prone, and EMR depends on accurate, not mostly accurate data. It just does not seem reasonable to make heavy use of a method that is labor intensive and error prone with no realistic imrprovement in sight, i.e. no matter how much better it gets, it still needs to be checked, and paradoxically, the more accurate it becomes the less carefully the user will check, thus making a critical error more likely over time. And if the checking is done properly, it takes time and the labor intensity therefore never improves. Scanning, by contrast, is accurate and requires no staff time to check. ALso, improvement is likely as scanners and computers get faster.

PDF is an option, however it has few benefits over simple scanning. The PDF is a little easier to manipulate than an image, but it is slower to create. Part of the downside of both OCR and PDF is that the stored report no longer exists as an original looking document which is a problem for some doctors who later use the file. Many would rather see the 'original report', not a 'synopsis' which re-formats the data. There is a much lower confidence level in altered than original looking documents.

Having said all this, in our own clinic we scan hundreds of documents daily. It is fast, convenient, permits multi-tasking by staff (who can be answering the phone while the scanner is doing its thing), and inexpensive. We have $150 flat beds that work just fine. They sit beside every staff person so they can 'file' in between other tasks. OCR and PDF scanning do not lend themselves to this multi-tasking environment thus rendering staff less efficient."

[Alan Brookstone]

For more information on scanning documents, read the new posting and comments - Scanning data - PDF vs. TIF files

[Fred Freedman]

I note that some people talk about reviewing letters to decide whether to scan them. If one is moving to a paperless office (after all is that not the main advantage of EMR) then doesn't one have to scan ALL reports? Where would you put the non scanned data? If you store it somewhere in paper than you have 2 parrallel systems...I would assume all reports/letters, etc must be scanned.

[Alan Brookstone]

Fred, great comment. I am also interested to hear what others are doing. I do the pre-screening of reports and information that come in regarding patients and find that there are about 20% that do not need to be scanned. These include hospital imaging reports that are done sequentially while the patients are treated as inpatients. There are also some 'nuisance' reports that do not add vlaue to the EMR - e.g. non solicited reports from nutritionists etc. As a result, I do not put all of these into the EMR - because all it does is cloud the patient record for future retrieval not to mention the cost of having as staff person scan an additional 20% more paper.

I am very interested to hear the experience of others in this area.

[Michael Rath]

Can someone comment on what is scanned into electronic record from an existing paper chart? Do you make a synopsis and throw away the old paper chart or scan in everything so that all the original notes exist?

This debate of high-end scanner versus multiple inexpensive scanners is also fascinating.

Does anyone have experience with PaperPort? Is there any other document management software that is recommended?

[Alan Brookstone]

Michael, my experience has been that one selects a starting date for EMR scanning and then begins to scan information into the system from that date forward. Generally you also want to put the allergy lists, long term meds and other important clinical information into the system.

The general wisdom is that it is not worthwhile to scan all information from the chart as this may not be of use in the future and will be very costly to enter.

I have not had experience with PaperPort, but would also be very interested to learn what others think about this product.

[Michael Rath]

I am on the verge of committing to electronic medical record. "MedAccess" has caught my attention because of the system architecture - a web-based server in the office with hourly backups to a remote server, with the ability to switch from one to another virtually seamlessly.
Last week I did some experimentation with a Gateway M275 tablet. The tablet had seemed to me to be a particularly elegant solution. In practice however I found myself worrying constantly that the thing would be knocked off a countertop. It was clumsy carrying it around with the microphone for voice-recognition. The "handwriting recognition" was a joke. Perhaps with the vocabulary from "Ablet" there would have been an improvement. In addition I found that if the tablet was placed on a countertop the viewing angle made it difficult to read. If something had to be typed in, the pop-up electronic keyboard was far more time-consuming than a regular keyboard upon which one can use all one's fingers. Even the selection of menu items can be problematic with the pen if the tablet doesn't happen to be at a convenient angle, lying on a countertop for instance. It is far too easy to miss the target. I have returned the machine to Future Shop and await the Next Generation. For approximately the cost of two tablets, I can equip my five examination rooms with inexpensive desktop computer systems. I have discovered a very elegant little wireless keyboard from "Gyration" that is the size of a laptop keyboard and takes up very little space on the countertop.

[John Fernandes]

I have a Compaq Tablet that I love. I agree with your concern about the limitation with respect to input to a tablet - it is awkward at best. Personally, I capture my notes on the tablet as handwritten notes saved with NO text recognition at all....that way I can use the extremely efficient "medical shorthand" that we all use to convey immense amounts of information with a very few pen strokes. The Clinic encounter is saved as an ongoing and never ending stream of notes. I only do this for consultations....routine office visits cannot be captured efficiently this way - I still use paper for those.
If you really have to type your notes in, it is FAR cheaper to have an EMR and dictate your notes into a voice capture file...you can then have your staff type in your notes just like a transcriptionist...I think, however, that it is far more efficient to simply use paper notes.

[Becky Middlebrook]

First of all thank-you to Dr.Brookstone for this website. We are in the planning stages of converting 13 years of paper. HELP!
I am currently (for my spouse)scanning the charts of non-active files of this specialist's office purely for the purpose of debulking the office before starting up with an EMR. But as any specialist repeat patients will appear. The result is purely a scanned format and can be reprinted if required. Maintaining the entire chart for the 10 required years for legal purposes whether by scanned or paper chart does not have any other option even if one creates a summary for the purpose of conversion to the EMR. My question is. Can scanned, stored files be later transfered to a new EMR. Has anyone else experienced this? Also is it suitable to discuss companies for those of us who have not yet launched? Any Nightingale users? Thirdly can I hear from a specialist who might be using mulitple sites. Ie Hospital clinics/ OR / Satellite Clinics.

[Alan Brookstone]

Becky, I think I can answer your first question. As long as the charts are scanned in a standard format - e.g. as Adobe .pdf files, or as image documents they should be attachable in any EMR in the future. The major issue you will face is catalogueing all of the scanning so that you can find it easily in the future when you want to attach it into an EMR system.

Perhaps specialist visitors to this site who had some experience with this issue would like to comment?

[David Woolliscroft]

Re scanning.

Some great comments here. We found the following:

Sheet fed scanner - HP 7450 works well we do not use OCR preferring the receptionist to review the scans and using the emr database it is fairly easy to allocate them.

We scan everything that comes in on paper. Xray, letters etc. We destroy the originals when the scan is complete. We prefer this route as we dont have to go looking for the lost sheet. By scanning everything we do not have to worry about missing an important one or giving (expecting) too much from the staff. Scanning everything with a shet fed scanner is not a great problem.

We chose not to scan the old chart in when we went to EMR as most of the info is irrelevant (out of date and would have entailed massive sorting to make it useful). Also we would be scanning dead files where the patient had moved on. Initially we had the charts pulled when we saw the patients and wrote in the EMR. If There was a particular letter, result etc we needed to refer to we marked and subsequently the staff scanned that piece of paper. By 6-9 months we have virtually everything that is useful. We only pull old charts which we specifically need and this is one or two a day. The saving in staff time has been enormous. At some point, when we feel the old charts are not being used, we will arrange to store them securely out of the office, prior to timely destruction.

We have chosen to scan first before the doctors see them as it ensures letter do not get lost etc.

[D Seguin]

My scanning problems are about to lessen. Our local hospital has agreed to work towards faxing imaging reports, then departmental reports, and finally lab results directly into my computer. It has taken 3 years of lobbying and pushing, but I expect this to happen by Sept 05. Almost all of my other data from all other sources already gets faxed directly into my EMR software in-box, whence it can be redirected by staff into the correct patient's record, to be "approved" by myself at a later time.
Meanwhile, I scan notices, patient brochures, educational articles, and other scraps into categories for later retrieval. For instance, choice photo diagnoses from throw-away medical journals are scanned, in colour, and make a great colour atlas of dermatology for bedside retrieval.

[Ron Joe]

I have three scanners but use one for most of day to day work.

1. Fujitsu 3097G+ (37 ppm simplex)
2. Fujitsu fi-4120c (25 ppm simplex or duplex)
3. Panasonic KVS 2055L (50 ppm simplex or duplex)

I find the fi-4120c is the best balance between speed and practicability. It has a very small footprint so it can be placed beside the secretaries phone. It’s 25 ppm so for the 100 or so daily documents only takes about 5 mins to scan. It has a reliable and straight feeder.

The advantage of the KVS 2055L is its pure speed. It’ll scan most charts in 1 – 2 mins and has a 300 page feed tray (big enough for most jobs). I have a Kofax Adrenaline interface card which does all the image processing (on the fly) i.e. auto-straightening, dot removal, character enhancement, bar-code detection etc. It’s got all the usual goodies like double feed detection, scan endorsement and a feeder that can take a stack of pages of varying sizes in one job. It also has a very nice built in image processing chip which gives you perfect images without fiddling with the brightness / contrast and gamma settings.

The advantage of the 3097G+, is the A3 flatbed which is useful for scanning things which are difficult to feed through the document feeder. It also has a good image processing chip as described above but really excels in bringing out light handwriting.

With high speed scanner’s no decision needs to be made about what’s to be scanned. “It’s all in” and be done with paper.