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This tongue-in-cheek essay hopes to prompt discussion among health information management (HIM) professionals of all levels with regard to the fast-changing HIM landscape, particularly the electronic health record (EHR) and the financial and career options that healthcare systems and employees have had to accept, adapt to, and decipher. Many of us have preconceived notions about how we will work within the new electronic environment as we help the implementation process succeed. Perhaps we need to also look at the negative impact some of these changes have had on HIM personnel. Some may find their tasks outsourced, obsolete, or expendable once the new EHR product they helped to implement is up and running. Do we really want all the paper to go away?
The electronic health record has arrived with much fanfare, preparation, expectation, and inevitable frustration. For those health information management (HIM) professionals fortunate enough to be on the cutting edge of technology, success in the electronic information realm represents a journey to be envied by those of us drowning in paper.
Purging, sorting, filing, shifting, and filming—all those pesky tasks centered on what to do with all that paper—reams of it. In a state-run facility, dealing with all that paper consumes hours of human effort, countless square feet of high-density shelving, and reels upon reels of microfilm. Volumes of long-term-care patient records are bursting at the rings with no room to file, no room to store years’ worth of files, and no scanning on the foreseeable horizon.
Is that the entire story? Does the electronic health record (EHR) solve everything? As a health information management professional with an advanced degree in HIM and the electronic record, I stand amid 52,000 inches of paper records wondering what the future holds. Even if the electronic record were implemented soon, the state healthcare system would remain a hybrid record for many years as back-scanning would be cost prohibitive. The retention schedule for government records is prolonged and convoluted. Get out the acid-free boxes for reel storage and fire up the microfilm reader. The past is the present here and will remain so for the indefinite future.
What would be the upside of all this paper in this unstable economy? To answer the question simply, an existing job. My compatriots in the private sector celebrated the electronic record in their healthcare systems until they came to work and found the HIM department literally dismantled and their jobs obsolete. And where did those jobs go? They went to health information management professionals with electronic record expertise, didn't they? Nope, those jobs went to temporary or preexisting information technology (IT) staff—you know, those friendly IT folks with no training regarding the content of the medical record. Those jobs went to the computer wizards, offsite IT employees who are now running the show. IT folks often unable to provide assistance with regard to content, regulatory standards, certification expectations, or requested program accessibility now manage the records. Constant software upgrades derail existing data relevance, confound already overwhelmed staff, and result in subjective data reporting. On the other hand, the electronic health record would be convenient, supposedly cost effective, and transportable between healthcare entities. And all that paper would be gone, unless one was required to print the page(s) anyway, as is often the case.
Wanting to remain “relevant,” I also work part-time in the private sector. There, I am exposed to the electronic record. I love the ease of patient data access (when the system is working) and connectivity to outside entities. I have two monitors in order to work more efficiently and extract data from multiple sites at once. Wow! What fun—if the server has not shut down, locked me out, or simply stating “not responding.” When the system is down or will not cooperate, my job comes to a halt. But for the most part, I have found the electronic record to be a major ally for data abstraction and reporting.
Documentation compliance is a different story. Enforcement of documentation requirements and content has been elusive. Getting the healthcare staff trained to enter data, such as problem lists or cancer staging forms, has been problematic. Chart components do not always exist. No one seems to follow up; it is so overwhelming, and exactly who is in charge? Consistency regarding the information scanned, the quality of the upload, and its end location varies. Deficiencies are posted and sometimes completed, sometimes not. We simply move on when necessary data are not available, and no one seems to be in charge of enforcing pertinent data availability. Many employees are overwhelmed keeping up with system upgrades, training, and new capabilities. All those newfangled tabs, buttons, arrows, pages, and screen options! Fun, fun, fun! Unless, of course, an employee tries to upload a history and physical (H&P) report, order a medication, complete a deficiency, open an attachment, or, of all things, actually take care of a patient.
Now, follow me back to my world of paper records. I still have a job, a big one. Someone has to shift all this processed wood around, complete analysis on content, and actually pursue follow-up. We have new high-density shelving, a beautiful reel cabinet within a specialized closet, and boxes upon boxes of records in storage waiting for microfilming. Several record specialists literally purge more than 12 inches of filing a day, each, and shift between two or three volumes of charts per patient. The typewriter still whirs for court paperwork that is not available online, and Master Patient Index cards are filed by hand in a drawer by the thousands. I know; I just moved them from old cabinets to new ones and labeled the drawers myself. My master's degree has assured me good spelling, labeling, and shifting capabilities. If the electronic record should come my way, would I have a job?
Yes, Virginia, there is a paper record. It will be here for a long time. I have to admit, though, I envy my private-sector HIM partners’ career relevancy and adventure. At the same time, I am grateful for my paycheck. I have my feet firmly planted on both sides of the fence. Where I will end up is not known. Where any of the devoted, trained HIM staff will end up is not nearly as clear as we had hoped or been led to believe.