Document Storage in AngelTrack

AngelTrack electronically stores patient documents, as they are uploaded by crews, dispatchers, and billers. A document can be attached to a dispatch, or it can be attached to a patient where it is then applied to multiple dispatches.

With AngelTrack, you can achieve the impossible EMS dream: a paperless office.

Paper documents


Uploading Paper Documents

There are several ways to get paper documents uploaded into the system.

Scanning

Flatbed and sheet-feed scanners work just fine for getting paper uploaded into AngelTrack. You can scan at any resolution you wish, but AngelTrack will convert very large scans back down to 200dpi for permanent storage. Likewise, AngelTrack converts most document types to grayscale, but in some circumstances this can be overridden if the document needs to be stored in color.

Some sheet-feed scanners can scan multiple documents into a single data-file. When doing so, select .PDF as the file type (rather than .TIFF), so that AngelTrack can then extract and separate all of the images. That allows you to scan everything to a single convenient file, and let AngelTrack pick it apart afterward.

Photographing

Any mobile device with an integrated camera can be used to photograph documents for upload. Just make sure of the following:

When any of AngelTrack's "Attach document" buttons is clicked on a mobile device, AngelTrack will activate the device's camera or its photo gallery. You can upload batch of photographs in one go, so with practice you can photograph and upload ten pages per minute.

Document photography using a smartphone

Your QA reviewers may need to fail a few run reports back to the crews, in order to train them what is and what is not acceptable quality in a photographed document.


Uploading Whole Web Pages

If you wish to attach a web page to a patient's file (or to a specific dispatch) in AngelTrack, you must follow these steps. This process is required because web browsers do a poor job of embedding child web-pages and child .PDFs in a parent webpage, thus your web-page will not display correctly when AngelTrack tries to include it in the assembled run report.

Here is how to do it:

  1. While viewing the desired web-page in your browser, scroll up or down until the pertinent information appears on your screen.
  2. Take a screenshot of the browser window.

    There are also "Screen-Grab" browser extensions for Chrome and Firefox that streamline the process of screenshotting webpages. Some of them can even screenshot the entire webpage, including the parts that are not currently showing on your monitor.

    Power users on Windows and Linux can -- alternatively -- take screen-shots by pressing ALT + PrintScreen. The PrintScreen key may be labelled PRTSCR. The screen-capture will be saved to the clipboard. You must paste it from there into your favorite imaging program or into the built-in paintbrush tool.

  3. Repeat step 2 if you need to capture multiple screenfulls of data.
  4. When all screen-captures have been taken, upload them all together to AngelTrack as a multi-page document, in the usual way.

Special Considerations for .PDF Documents

Many sheet-feed scanners produce a single .PDF document containing all of the page scans. If you upload this .PDF, AngelTrack will search through it and extract all useful images from it. (Small images, such as logos and decorations, will be ignored.) If the .PDF turns out to contain no large images -- i.e. if the .PDF is all text and layout -- then it will be stored whole.

This image-extraction feature is controlled by the ☑ Extract images from .PDFs checkbox, present on most pages in AngelTrack that accept file uploads. Uncheck the box to force AngelTrack to store the .PDF document whole even if it contains large embedded images... but keep in mind that many web browsers cannot print whole .PDF documents, nor can they usefully export them to other formats. For that reason, it is generally best to extract the images and store them separately.

.PDF documents containing embedded JPEG 2000 images

Certain printers and digital cameras produce their output as a .PDF containing the images encoded using the JPEG 2000 format. JPEG 2000 is a patent-encumbered format that is not supported by AngelTrack. AngelTrack supports regular JPEG (aka JFIF) instead.

To deal with this, you may simply need to update your scanner's driver software, or update the device's PC control panel software. If that fails, look inside the scanner's settings to see if it offers a choice of image encoding. Choose regular JPEG instead, or PNG, or BMP.

AngelTrack will warn you if an uploaded .PDF file contains images in JPEG 2000 format. You are free to ignore the warning, and upload the .PDF to AngelTrack anyway. AngelTrack will not be able to extract any images from it, and so instead will store the .PDF whole. It can be retrieved later, but its contents cannot automatically appear inside AngelTrack's run reports, the way that all other documents do.


Conversion, Resolution, and Greyscaling

All images (other than TIFF) uploaded to AngelTrack will be forcibly re-encoded as JPEG images, as a security measure against the threat of image-born computer viruses. Re-encoding of images will strip out any malicious payload that might otherwise infect the computers in your backoffice.

During re-encoding, images will be resized to fit within a 2048 x 2048 square, which is approximately 200dpi, equivalent to the "Fine" setting on a fax machine. This resolution was chosen to preserve readability while minimizing bandwidth, processing power, and the burden of long-term online storage. The 2048 x 2048 limit applies to all document types except portraits: employee, vehicle, and patient portraits are resized to a 400 x 400 square instead.

Before

Actual document photo taken using iPhone 5S

3264x2448
before
click to view actual size
sample of before
full-size sample

After

Actual conversion performed by AngelTrack

2048x1536
after
click to view actual size
sample of after
full-size sample

Portraits, ECG strips, announcements, and vehicle damage photos are all stored in full color. All other document types are converted to greyscale, again for the benefit of faster processing and downloading. Some pages in AngelTrack allow you to override the greyscale conversion and store the document in full-color, as you see fit.

Quality problems are the result of poor photography

As you can see in the sample above, AngelTrack's document system preserves sufficient image quality for the purpose of billing and compliance.

Therefore if documents provided by crew members are not legible, the problem is the mobile devices or the technique. The Document Upload Guide explains the proper technique for performing document photography using smartphones and tablets.


Document Persistence and Sharing Across Dispatches

When crew members, billers, and dispatchers upload patient documents into AngelTrack, they are automatically shared across the patient's dispatches.

The following chart shows the rules for automatic sharing:

Document Type Appears In
Against Medical Advice (AMA) Only the dispatch it is specifically attached to.
Does not appear anywhere else -- not even the return-trip.
Auth/Xfer signatures
Telemedicine consult
DNR, standard form All of the patient's dispatches forever, until superceded.
See special DNR rules below.
DNR, advanced directive
DNR revocation
Face sheet All of the patient's dispatches for the next 60 days*.
The number of days is a configurable preference setting; default is 60.
Only the youngest document of each type will appear in a run report.
Insurance cards
Medication list
Physical / Progress
Past medical history (PMHx)
Diagnostic image
Advanced directive without DNR
Other (see comments) All of the patient's dispatches occurring the same day.
Physician Certification Statement (PCS) All of the patient's dispatches for the date range specified (1 to 60 days).
Prior Authorization Number (PAN)
Emergency contacts / Special needs All of the patient's dispatches forever, until superceded.

*Documents are shared forward into the future, not backward into the past

Of all document types that are shared across a date range of dispatches, they are always shared forward in time, never backward in time.

That means that a document attached today will appear in the patient's dispatches for the next 60 days, but it will not appear in yesterday's dispatches. This conservative rule guarantees that new information -- which might have become available only today -- does not cast yesterday's services in the wrong light.

For example, if the patient had his first psychotic episode just this morning, the new face sheet will say "Requires restraints", where none were required before. If that new face sheet were to appear in yesterday's run report, it would raise unpleasant questions along the lines of "Why did you not restrain this patient?!"... until (hopefully) somebody eventually compares the date on the document against the date of the transport.


Attaching to a Dispatch Versus Attaching to a Patient

AngelTrack allows documents to be attached in two ways: to a dispatch, and to a patient.

The rules for document sharing -- shown in the table just above -- apply equally, no matter how a document is attached.

Attaching to a dispatch

In general, attaching to a dispatch is done by crew members, using the PCR.

When they do so, the PCR ensures that the document is attached to the correct dispatch; the crew is not required to look up a patient record or check a date-of-birth. They are protected from making a mistake.

And there is another benefit: when a document is attached to a dispatch, it remains so even if the dispatcher discovers that the wrong patient record is attached, and switches it out for the correct one. The crew's documents remain unperturbed, since they were not attached to the patient.

Crew members have authority to delete documents that they uploaded accidentally, or that are found to be illegible.

Dispatchers and billers can also attach documents directly to a dispatch, by using the "Documents" tab of the Dispatch Edit page. They can also remove errant documents no matter who uploaded them.

Attaching to a patient

In general, attaching a document to a patient is done by dispatchers and billers, using these AngelTrack pages:

The attached documents automatically appear in all of the patient's run reports, according to the rules given in the chart above. They can also be retrieved later using the Librarian -- more about that below.

Special cases

There are a few special cases that do not fit within the above explanation.

  1. DNR documents are always given special handling, regardless of who attaches them, and regardless of which AngelTrack page is used to do so. See below for an explanation of the DNR rules.
  2. Multi-day PCS documents -- created with the PCR's ePCS form -- are always attached to the patient record, not to the dispatch record. One-day PCS documents are not.

DNR and DNR Revocation Documents

DNR and DNR Revocation documents are always treated as patient documents, not dispatch documents, regardless of who uploads them or where they upload them from. As such, they follow the patient, automatically appearing in every dispatch that occurs on or after the document's date.

(Normally, documents uploaded by crew members are always attached to the dispatch record, not the patient record. DNR and DNR Revocation documents are the exception to this rule.)

A DNR document remains valid forever, until either a newer DNR document is uploaded, or a DNR revocation is uploaded. In the event of a revocation, the revocation document then follows the patient -- appearing in all relevant dispatches -- forever until replaced by a newer revocation or a newer DNR.

Each patient record has a DNR flag that causes a warning to appear on dispatcher and crew screens when servicing the patient. The DNR flag can be set or cleared by dispatchers and (using the PCR) by crews... but it will also be automatically set whenever someone uploads a DNR document for the patient. Likewise, it will be automatically unset when a newer revocation document is uploaded.

To learn more, read the DNRs and DNR Revocations Guide.


Document and Image Formats

AngelTrack accepts any type of document for upload. Here is how the different types of document are processed:

Document type Upload Retrieval
JPG/JPEG Re-encoded as JPG Displayed in all associated run reports (including PDFs of run reports)
Can download copies
PNG
BMP
GIF
SVG
Converted to JPG
PDF Your choice:
  • PDF is stored whole; or
  • The PDF is searched for embedded images:
    • Embedded images smaller than 100x100 are ignored
    • Embedded images larger than 100x100 are extracted
    • All other text and formatting is discarded
Extracted images are displayed in all associated run reports (including PDFs of run reports)
Can download copies of the images
TIF/TIFF Stored whole Displayed in all associated run reports if viewed with a TIFF-compatible browser
Can download copies
All others Inspected to see if actually a PDF
If not, stored whole
Not displayed in run reports, except as links
Must download a copy to view using an appropriate application

Librarian

Over time, frequent flier patients will accumulate many documents. AngelTrack provides a Librarian feature to simplify the task of finding the correct document. Each patient's Patient Edit page contains a "Librarian" tab with this feature, and there is also a Patient Document Librarian page (available from the Billing home page) which can find matching documents across all patients by last name and date of birth.

The Librarian searches for documents based on a specified date. It will return the youngest document that existed on that date. So, if there are three medication lists, for January 1, February 1, and March 1, the youngest medication list as of February 15th is the one from February 1, since the March 1 document didn't exist yet.

It can also be told return all documents that existed on that date, even older ones that have been supplanted.


Automatic De-Duplication

Documents uploaded to AngelTrack are automatically de-duplicated, with page-level granularity. This means that if one page scan (say, a patient's medical history) is uploaded to four different dispatches, the page scan will be stored only once, with all four dispatches referring to it.

As a result, there is no performance or diskspace penalty for uploading the same scan as many times as is necessary. So, upload documents to dispatches and to patients in any manner you see fit.


Deletion and Undeletion

Documents can be soft-deleted and un-deleted at will. Once deleted, a document stops appearing in run reports... until un-deleted again.

Document list

Billers and dispatchers are allowed to delete and un-delete any document, regardless of who uploaded it or what dispatches or patient it is attached to. For this reason they must take care what they delete, because documents can appear in many dispatches, sometimes across broad swathes of runs.

Crew members are allowed to delete and un-delete any document that they did personally upload. They can do so only from the PCR Documents page, and only for documents that they attached to the current dispatch. If they uploaded a document a week ago, and it now appears in a call for today, they cannot delete the document from today's call -- lest they perturb last week's report which has already passed QA.

If an older document is appearing in a newer run report, and the crew doesn't want it there, they can hide it by uploading a newer version of it. For example, if last month's face sheet appears in a call today, but the face sheet is outdated, the crew must upload an updated face sheet. The updated document will then hide the outdated document, because as the rules say, only the latest face sheet is displayed.

No hard deletion

Documents can be soft-deleted and un-deleted, but there is no way to actually remove a document from AngelTrack. Not even the administrator can do it. Once a document is uploaded, it's there forever.

This is intentional. It protects you from mistakes made by careless/distracted employees, and from disgruntled employees who might seek to cause damage by quietly removing data from AngelTrack over a period of time.

If you have a business need to hard-delete a document and are certain you won't change your mind later, contact your AngelTrack support line and request the deletion.



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