EXECUTIVE SUMMARY
Hospitals that have tried to shed their reliance on paper have found the task fraught with challenges. Some have found that document imaging provides a useful interim step in meeting their goal.
If the ultimate goal for a hospital is to become 100 percent paperless, then document imaging has to be at least an intermediate step in achieving that goal. And for chief information officers who are facing this paperless challenge, scanning paper documents into appropriate information systems has to become an integral part of their overall strategy.
But given the amount of paper still being generated from both inside and outside of hospitals, is this goal achievable? “The concept of a true paperless hospital will never exist,” says Russell Branzell, CIO and vice president of information services at Poudre Valley Health System in Fort Collins, Colo.
For Sue Schade, vice president and CIO of Brigham and Women's Hospital in Boston, Mass., the issue is one of degrees. “Are we ever going to be paperless or just use less paper?” she asks.
INCREMENTAL CHANGES
Schade says her hospital is in the process of implementing clinical documentation systems for both physicians and nurses that will greatly reduce the amount of paper now being generated on the clinical side. Having already installed separate ambulatory and inpatient electronic health records (EHRs), Brigham and Women's Hospital has put into place a document imaging strategy. “We did this as a bridge strategy until clinical documentation goes online,” she says.
Schade acknowledges there was a second reason for implementing this strategy: the organization's Health Information Management Group and all stored patient records needed to be moved to an offsite facility because of space constraints within the hospital.
In addition to scanning paper documents that are still being generated by clinicians, the hospital scans every patient's chart upon their discharge. “One day after discharge, the scanned documents are available online,” she says.
Document imaging as an interim step in going paperless also has been a successful strategy for CentraState Healthcare System, says Indranil Ganguly, vice president and CIO of the Freehold, N.J.-based provider. Major parts of all inpatient records such as physicians’ progress notes and consent forms are still paper documents that need to get scanned into the EHR, he says. And while all nursing documentation is already being done online, this 282-bed hospital still relies on the traditional paper chart. However, Ganguly notes, “We are totally paperless post-discharge.”
Within 48 hours of discharge, a patient's chart goes to the medical records department where the staff processes the chart, runs the necessary quality control checks, and then scans all paper documents into an EHR. Once that process is completed, the paper charts are destroyed. “We've been doing this about four years,” Ganguly says.
It's somewhat different, though, when a patient is admitted. At that point initial consent forms are captured using an electronic signature pad, he says. Patients transferred from another facility or referring physcian usually bring paper documents with them. Upon admission, all pertinent information from these documents is manually keyed into that patient's EHR.
It's no surprise that these strategies and other efforts to go paperless have created some challenges. The integration of systems is always a major challenge, as is the attempt to change old habits, Ganguly says. Fortunately, physicians have gotten better at checking computers before they get to a patient's room, he says.
THE DIGITAL DIVIDE
Russell Branzell knows how difficult it is to try to eliminate paper from all departments within a hospital and that it may take more than one strategy to achieve a modicum of success. As yet, not all physician documentation is being entered directly into a patient's EHR, and there are still some patients-mainly from rural areas-that bring paper records with them when being referred by a physician practice or other healthcare facility, he says. Nonetheless, Branzell notes that that over the past two years he's seen a significant drop in the amount of paper being generated by, or coming into, Poudre Valley.
Part of the decline is due to the use of document imaging as an interim strategy in becoming a paperless healthcare system. “We started the scanning process four years ago and went hyperdrive when we opened a new facility in February 2007 with one-third paper,” he says.
But the paperless process actually began in 2004 when Poudre Valley launched its EHR and then did a complete upgrade of the entire system this past October. And it also took another big step when it invested in voice recognition software so a physician's dictated notes could be available online within 24 hours.
As is usually the case with implementing paperless strategies, there were some challenges, which Branzell categorizes most of them as workflow issues. “People are used to a chart being set up a certain way,” he says. The presentation of data also took some getting used to since there is a definite difference between codified data and a scanned image of a document.
Plus, Branzell explains, a lot of people on both the clinical and business side still like to retain hard copies of documents even after the data have been entered electronically.
If active medical records in a paper format are becoming a thing of the past, archived paper records are meeting the same fate. “Our medical records department has no shelves,” Branzell says.
Paper records, some dating back to the 1940s, have been systematically purged over the years. Given the technology of the day, many of these early records were put on microfiche. But with today's digital scanning technology, any archived record that still considered active are being selectively scanned, he says.
On the business side, paper documents also are scanned into the appropriate information system. And similar to documents on the clinical side, this information becomes immediately available online.
In addition, Branzell says, “We selected an outside contractor to handle all legal contracts so we can do contract management.” In the past, contracts with vendors, payers, and even hospital directors were “scattered in various places in a paper format,” he says. Now these contracts are all in an electronic format with a built-in tickler system.
A LONG JOURNEY
Moving toward a paperless environment takes time, says Charles Christian, CIO and director of information systems at Good Samaritan Hospital in Vincennes, Ind. “We started using document imaging 13 years ago to streamline our revenue cycle in order to capture documents in the beginning of the cycle instead of archiving them.” he says. “We found we had four FTE file clerks doing seven FTEs worth of work.”
The hospital also has spent the last 10 years analyzing all of its clinical processes and incrementally rolling out an EHR. The initial strategy on the clinical side of this 232-bed hospital was to move as much as possible to an electronic format. This included lab and radiology results as well as transcribed reports. Anything still on paper, like physician orders and nursing documentation, was scanned into a document management system which was ultimately upgraded to an automated workflow system with a feature that now reminds physicians which documents still need their electronic signature.
Once the documents are scanned, clinicians have almost instantaneous access to the data, Christian says, adding, “We don't scan things that were already electronically entered.”
After these paper documents are scanned, they are kept on file for 150 days and then destroyed. Forty-eight hours after a patient's discharge, the entire chart is available online.
A similar strategy is being used in the hospital's business offices. “On the financial side, there's a lot of paper that comes in. But anything we can move electronically, we don't touch,” Christian says.
In many cases documents are converted into COLD (Computer Output to Laser Disk) images, which could include imbedded PDFs, he says.
Archived patient records have also presented document imaging opportunities. Because of space constraints, old medical records were originally put on microfiche. By using an in-house created application and outsourcing the work, about six years worth of the tens-of-thousands of archived medical records have been scanned and are now stored on a hard drive and laser disks. “We've been pretty progressive in the use of technology,” Christian says.
Richard R. Rogosky is a freelance writer based in Durham, N.C. Healthcare Informatics 2011 January;28(1):24-26
