Automating your document management system

Oct. 16, 2013

Knox Community Hospital improves document workflows with enterprise technology.

Maintaining the delicate balance between efficiency and patient safety can be difficult for hospitals. Knox Community Hospital, a 115-bed, not-for-profit facility in Mount Vernon, Ohio, walked this tightrope routinely with their past document management processes.

For many years, Knox Community manually compiled document “kits” that contained all of the forms associated with a particular procedure, a given physician or a particular unit. The process was useful for ensuring all necessary documentation was provided for the patients, but the kits required a labor-intensive assembly process. Volunteers or staff members had to be tasked with collecting each form to be included in each kit, one by one.

Knox Community offers both acute inpatient and outpatient services and maintains a medical staff of approximately 60 physicians; about 30 are employed physicians. The ability to keep physicians and clinical staff aligned regarding the documents provided to patients is of utmost importance. The entirely manual forms management processes offered little support.

Additional pitfalls of relying solely on pre-printed forms included requiring hospital staff to locate the correct forms and forcing them to hand-write any patient-specific information on the documents. Not surprisingly, legibility issues sometimes arose – especially if copies had to be made for the patient, medical unit and medical record.

Given the sheer volume of paperwork, ensuring that each hospital unit was using the most up-to-date versions of all documents was challenging. There was no central repository for documents, which meant each unit typically kept printed copies of a variety of forms on hand. In addition to potential revision issues, when staff members needed a certain document, they were forced to stop their other activities to search for the owner of the document in order to make revisions.

(Left to right) Deb Weaver, HIM director and chairperson of the Forms Committee at Knox Community Hospital, and committee members Robbi Jo Mitchell-Enderle, Todd Williams, Sonna Harding and Katy Breeze.

Compounding the workflow inefficiencies was the fact that the manual processes had the potential for patient-safety ramifications. Consider a scenario in which the recommended dosing instructions for a particular medication are changed. Stockpiled forms in drawers and closets might not be updated with the current information. This could pose a safety risk to any patient provided with the outdated information. Indeed, the hospital’s move toward an electronic health record (EHR) and associated electronic medication reconciliation was one impetus for a more automated forms management process.

Searching for solutions

A few years ago, Knox Community made the decision to transition to an EHR. At the same time, the hospital’s Forms Committee – which works to ensure that the content of all documents meets compliance standards – began searching for new ways to maintain both patient forms and registration documents.

As selection of the two technologies progressed, it quickly became apparent that bar-coding capability would play an important role. None of the hospital’s forms up until that point included barcodes; staff manually attached stickers that included bar-coded patient demographic data. The Forms Committee realized an EHR implementation meant not only that existing forms would need to be scanned into the system, but also that the ability to promptly and accurately capture forms data in the EHR would be essential.

The Forms Committee identified several specific requirements its automated document management system had to meet:

  • In-house manipulation. In-house staff had to be able to make changes to documents without going back to the vendor. Previously, the printing company that created forms for Knox Community provided proofs just before final printing, but any changes brought about an extra fee and a one-week delay.
  • Centralized access. The Forms Committee wanted a solution that would expedite any enterprise-wide document changes. For example, if a pre-surgical instruction changed on one form and was applicable to many different forms, the committee desired the ability to search and update all applicable forms simultaneously.
  • Ease of use. The ability for staff to quickly and easily locate the most current version of the correct form was imperative.
  • Bar coding. Before automating the forms management workflow, only those forms specific to patient care registration information included bar-coded data. The Forms Committee saw value in bar coding not only patient-specific paperwork, but also general material such as patient education documents.
  • Regulatory compliance and disaster preparedness. The ability to ensure forms meet Joint Commission, CMS and other standards was necessary. Equally important was the capability to register patients and provide care during an EHR downtime event.

Because Knox Community was implementing an EHR simultaneously, the Forms Committee knew that one additional factor would be critical to obtaining buy-in for any new document management solution: it had to roll out with minimal education and training requirements.

Reaping the benefits

In June 2012, the hospital implemented its EHR (Horizon Patient Folder, McKesson Corporation) and Enterprise Documentation Management Solution (SMARTworks Clinical Enterprise, Standard Register Healthcare) that enables the configuration, distribution and management of both printed and electronic documents.

Prior to go-live, the Forms Committee assembled a team to prepare existing forms to be entered into the system. In a matter of just 2 1/2 weeks, all 740 forms were entered. All staff were trained to use the enterprise documentation management solution as part of their overall EHR education, but most essentially taught themselves how to navigate it and embraced it quickly.

Although the enterprise documentation management solution is tightly integrated with the EHR, it is important to note that it remains independent of the EHR. This fact sometimes provides an unexpected bonus: Even if the EHR goes down, staff can still access the forms and order sets they need, helping ensure procedures and other activities proceed as planned, without delay.

In fact, even without an EHR, the Forms Committee firmly believes the simple step of automating document management would have improved workflows dramatically. Additional workflow and process improvements experienced since implementation include:

  • Standardization and compliance. All documents now have consistent content as well as a standard look and feel. Furthermore, the Forms Committee can ensure staff are accessing only the most current and compliant versions of all forms. There is no longer the danger of inadvertently using an outdated form.
  • Immediate access. Wholesale changes can be made quickly to all forms, and those updates are immediately available to staff. Documents can be accessed with the click of a mouse from any desktop within the hospital network.
  • Efficiency. The ability to print current versions of bar-coded documents on demand has had a significant impact on scanning throughput. The HIM staff has been able to streamline workflows to ensure that all patient documents are quickly available within the EHR and accessible by providers as required. For example, the turnaround time for records to be scanned and available for users now falls within 12 hours of discharge; previously, it could take up to a couple of days during periods of high patient volume.
  • Space savings. Forms now are housed electronically and printed on demand, eliminating the need to keep stacks of paper copies on the units. Significantly, there are no wasted forms. The hospital actually removed three pallets of documents from its materials store room.
  • Cost savings. The Forms Committee found that the enterprise documentation management solution afforded the hospital immediate savings at go-live by increasing staff time efficiencies and drastically reducing document procurement costs: total savings are estimated to be in the range of $400,000 per year.

Perhaps the most popular feature to end users is ease of access. Staff now are able to easily search for any form they need by multiple methods. An exact title is not necessary; they can search by partial title, form number or keyword. Moreover, documents can be viewed before printing to ensure they are the ones desired.

Earlier, we spoke of the labor-intensive procedure to prepare document “kits.” The ability of the enterprise documentation management solution to automate that process has had a major impact on clinical and nursing workflows. A number of patients undergoing the same procedure can be batch selected, and the kits assembled and customized for each patient with just the touch of a button. It is expected that this significant workflow improvement ultimately affords more time for direct patient care.

Achieving balance

After a year with the enterprise documentation management solution in place, Knox Community Hospital’s Forms Committee is pleased with the workflow and patient-safety improvements it has achieved. Staff have easier access to standardized and compliant documents, allowing physicians and nurses to focus their attention on patient care. The staff find it comforting to know that they are using the most up-to-date documents, and thus securing the safety of their patients.

In years past, Knox Community had to hand-touch every form it used. Today, it has struck a much better balance between efficiency and patient safety with the implementation of automated document management workflows.

About the primary author

Deborah Weaver is the HIM director and chairperson of the Forms Committee at Knox Community Hospital in Mount Vernon, Ohio.

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