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Going Paperless
With Electronic Archiving
By Stanford I. Lamberg, MD

Stanford I. Lamberg, MD, is Associate Professor of Dermatology, Johns Hopkins Medicine, and in private practice in Baltimore. He has authored several books. The latest is Blackwell’s Primary Care Essentials: Dermatology, published in 2002. He designed the scanning software described in this article to get out from under the mountain of records accumulating in his office and basement.

Depending on the state, specialty, and the age of the patient, physicians must store records for years, sometimes “forever.” Electronic record storage, increasingly easy and cost-effective, can help physicians dig themselves out from under a mountain of old paper charts and ease retrieval of the record when it is needed.

Most states require that adult patients’ records be retained for seven to 10 years. Medicare requires seven years. Children’s records must be held until the age of majority, plus a varying number of additional years in different states. Certain birth records must be kept indefinitely. The site www.medicalliabilitymonitor.com advises physicians to indefinitely retain records of patients who had complications after treatment or surgery, who died during treatment, received treatment for cancer or heart disease, or who had traumatic injuries that could or did result in litigation.ⁱ

Ten percent of lawsuits filed against physicians in all medical specialties are not brought until five years or more after the incident (TABLE 1). This liability exposure leads malpractice insurance carriers to advise physicians to keep records as long as possible, even indefinitely, as insurers find it easier to defend the physician if a record is available than to contend with the physician’s and patient’s memories.ⁱⁱ Additionally, there is no “statute of limitations” in regards to administrative actions by state licensing boards, which may require a physician to respond to a complaint many years after an incident.

Problems With Storage of Paper Charts

Too little office storage space
There’s never enough space to store patient charts in the office. Many physicians give expensive office floor space to storing thousands of charts that haven’t been pulled for years. Specialties vary in their needs for long-term storage. Dermatologists either have patients under chronic care, or see a patient for a single event and then may not see the patient again for years.

Searching takes too long
Most physicians keep active patient charts near the front office. They often put charts that have not been needed for a year or two in a back hallway, an exam room turned into a record room, or their consultation room. Some store records offsite, in their home basement or attic, or in a rental storage facility. When inactive charts are needed, office staff must leave the front desk to search the back office. Often, they realize only after a time-consuming and fruitless office search that the record is stored offsite.

Costs of long-term paper storage and retrieval
Maintenance and support of paper records generates significant expenses. Table 2 demonstrates the costs of paper chart storage and retrieval in a typical practice for a patient whose records are not in the front office. To retrieve the records, the office staff must leave the front desk to search. Even if the staff person takes only five minutes to search, and needs to find only 10 records that day, the cost to the office could be up to $3,250 a year (five min x 10 charts x five days/wk x 52 wks/yr for a $15/hr staff salary). If two of those 10 records have been sent to off-site storage, adding up to 20 records retrieved every two weeks, and if the cost of each trip is estimated at $50, the yearly cost is $1,300. If an off-site storage facility is rented at $100/month, add another $1,200, or if office space is used that could better be used for patient care, add at least $640 (four file racks at $20/ft2). Other costs include the yearly purchase of new file folders (typically about $500). Thus, the yearly costs for dealing with storage and retrieval of inactive charts kept as paper records is about $6,250. Unless the system changes, the costs for each year remain the same for a total cost for three years of $18,750. (Note that the cost for the fourth year is based on the same $6,250 as the first year, although staff salaries may have increased by that time.)

Scanning Records Saves Space, Time, and Money
Problems with paper storage, particularly demands on space and time, can be eliminated if the charts are transferred to digital media by scanning them into a computer. Scanning and saving to the computer is particularly valid if your state allows the paper copies to be destroyed. Virginia law, for example, permits records to be stored by “computerized or other electronic process or microfilm, or other photographic, mechanical, or chemical process,” so long as “the process creates an unalterable record.”ⁱⁱⁱ Check with your state medical society to see if such laws apply to your paper records.

Scanning has become practical in the last several years, thanks to inexpensive high-capacity hard drives, and inexpensive, fast scanners equipped with automatic document feeders. By using scanning, physicians can remove old paper records from the office, enable staff to locate records without leaving the front desk, and curtail offsite storage expenses. The initial scanning of records remains the most significant impediment. Available software, however, makes the process easy enough that a high-school student can scan thousands of records in a few weeks in the summer.

Costs of SCANNING for Image Storage and Retrieval
While scanning inactive records eliminates the substantial costs associated with paper records, it adds new—though lesser—-costs: scanning, image storage, and retrieval. These costs are outlined in Table 3, which illustrates how an unskilled worker (say, a high school student at $7.50/hr) can scan 10,000 records in five weeks at a cost of $1,500. When you compare this cost, plus the cost of the scanner and software, the cost of record retrieval, and, especially, the cost of record storage with the costs associated with paper records, the savings quickly become apparent. For example, it takes only three months to recover the costs of scanning compared to paper storage.

Scanning Software and Hardware
Hardware: Computers, scanners and backup devices are relatively inexpensive, and easily capable of performing the necessary scanning functions. Hard drive space today is not a limiting factor, as it was just a few years ago. About 10,000 patient charts, each averaging 10 pages, can be stored in a couple of gigabytes. Since computers now typically come with a minimum of 40 gigabyte hard drives, they provide more than adequate space to store records. A scanner with an automatic document feeder that can scan 15 pages a minute and both sides of the page at the same time costs less than $1,000. Further information on hardware may be found at www.pcarchiver.com/hardware.html.

Software: The ideal software must: (a) be easy enough to use that an unskilled worker, such as a high-school student, can scan and index records; (b) have query options to find scanned records quickly; (c) have flexible database options to meet specific needs for different specialties and purposes; (d) allow the appending of new chart pages when needed; and (e) allow access to the database from a server so that all qualified users may examine or print the patient chart when needed.

In addition, the images must be created in a form secure from alteration or tampering. Images stored as “pictures” theoretically can be modified, but doing so is not within the realm of the typical user. Further, changes cannot be made without leaving a footprint that an expert can detect. The images should be stored in a manner that is an industry standard (i.e. .jpg or .tif), so that other programs can read the files. Finally, the storage media must be stable. Because decades-long stability on any recording media, including CD-ROMs, still is not known, data should be migrated every five to 10 years.^iv

Technology exists to scan charts and read the text using optical character recognition (OCR) technology. This technology sometimes is used in legal and insurance offices, but it is not suitable for scanning patient records. OCR works well only with typewritten words. The process is extremely time-consuming to run, and consumes large amounts of disk space. It requires proofreading the scanned material. It would also alter the format of the original material to such an extent that it would lose the equivalency of the paper record. A review of some of these issues appeared in Physicians Internet Review.^v

Software specifically designed for medical scanning and storage usually is incorporated within programs that offer full electronic medical record (EMR) implementation. If you are not ready to change over to full EMR, stand-alone software designed for the medical office is available. Among these are the author’s own program, PCArchiver (www.pcarchiver.com), and SRS Software (www.srssoftware.com/index.html). An additional option is to have patient charts scanned off-site to CD-ROMs or microfiche. This is expensive and is generally used only by hospitals and large medical groups.

While records must be stored for years, and it may be prudent to keep some indefinitely, quality of patient care suffers if the patient record is unavailable or not easily accessible. Retrieval and file space for paper records is costly. Computer storage and scanning hardware and software now cost less than paper storage, and are fast and easy to implement. These new technologies warrant consideration as an alternative to paper storage.

i Loss Minimizer “Malpractice Liability Questions and Answers: Part III,” www.medicalliabilitymonitor.com/, May 1994.

ii GE Medical Protective, Clinical Risk Management Department, (personal communication, Kathleen M. Roman, Assistant Vice President, Risk Management Education Services, Risk Management, Jan 8, 2003).

iii Va. Code Ann. of Virginia § 54.1-2403.2. (1998) Record storage. Medical records may be stored by computerized or other electronic process or microfilm, or other photographic, mechanical, or chemical process; however, the stored record shall identify the location of any documents or information that could not be so technologically stored. If the technological storage process creates an unalterable record, a health care provider licensed, certified or registered by a health regulatory board within the Department shall not be required to maintain paper copies of medical records that have been stored by computerized or other electronic process, microfilm, or other photographic, mechanical, or chemical process. Upon completing such technological storage, paper copies of medical records may be destroyed in a manner that preserves the patient’s confidentiality. However, any documents or information that could not be so technologically stored shall be preserved. (emphasis added)

iv Maryland State Medical Society; 1211 Cathedral Street, Baltimore MD 21201; 800.492.1056, ext. 309 “MedChi Resource Directory, The Office Medical Record: Confidentially and Disclosure—FAQs;” 1999.

v Siegel D, “Space…The Final Frontier.” Physicians Internet Review, May/June 2002.

You can e-mail Dr. Lamberg with questions or comments at SLamberg@JHU.edu. Learn more about scanning patient records by visiting his website at www.pcarchiver.com.

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