The transition to an EMR can be a complex and lengthy process, and most hospitals (even those that have deployed an EMR) have found themselves handling a mix of paper and electronic documents.

The Cleveland Clinic has an even larger document management challenge than most hospitals — the nationally known non-profit organization manages records on more than 5 million patients across 20 facilities (including nine community hospitals). In July 2006, the Clinic selected Westlake, Ohio-based Hyland Software's OnBase document management system to get a better handle on its records as it deployed Epic Systems’ (Verona, Wis.) EMR. Although the system is still not fully deployed, the Clinic is already seeing results.

“When a patient comes in and you have those documents readily available, that provides a significant improvement in quality,” says Robert Juhasz, D.O., associate medical director at Cleveland Clinic. “Instead of searching for documents, the information is available right there on your computer, in a timely fashion.”

Document management and imaging (DMI) systems are considered a crucial part of the migration to an EMR, and can help a hospital better manage both its paper and electronic documents. “Many healthcare providers are looking to document and records management systems both to improve patient care and to improve their billing operations,” says Rebecca Wettemann, vice president of research at Wellesley, Mass.-based Nucleus Research.

DMI solutions vendors have responded by providing a wide range of capabilities, from basic document imaging and workflow management to electronic forms creation and electronic charting — blurring the lines between DMI and EMR. In some cases, hospitals are using electronic document management as a stepping stone to a full-blown EMR, while for smaller facilities the document management system essentially functions as the full electronic record.

ProMedica Health Systems, a nine-hospital organization in Toledo, Ohio, has deployed Cincinnati-based Streamline Health Solutions’ document management application across its facilities in combination with 3M Health Information System's (Murray, Utah) clinical data repository and a fully integrated PACS. “The combination of those three technologies satisfies a large portion of our physicians’ needs,” says ProMedica CIO David Selman. “The Streamline system is one of the key components of our overall technology strategy.”

Selman is not alone in banking on the application. “The vendors have this vision of what document management can become, which is a key piece of the overall EMR,” says Jared Peterson, vice president of operations at KLAS, Orem, Utah. “They are becoming a key part of what the physician sees, and how the business office views the overall medical record.”

Analyzing and resolving the spend

A DMI system can be cost justified using a variety of factors, but the primary benefit is increased productivity for clinicians and HIM staff. “Physicians and hospital staff spend less time looking for information,” Wettemann says. “Patient care is improved, because you're able to route patients more quickly to the next appropriate step in their care.”

A robust DMI can speed the billing cycle, prevent loss of paperwork, improve the admissions process, increase the availability of documents, and reduce the cost of storing paper documents. A DMI can automatically route and process documents, saving time and labor in the HIM department, and speed fulfillment of release of information requests. By scanning and compiling documents electronically, hospitals are able to provide simultaneous access to patient records, so charts don't have be shuttled between departments.

“We actually had to adjust our productivity targets because the staff is so much more efficient now,” says Barbara Knight, director of health information at Sun Health in Sun City, Ariz. “Our analysis staff has doubled their expected productivity goals because of how quickly they can process a record.”

Sun, which operates two acute care facilities and a rehab center, is using the ChartMaxx solution from MedPlus (Mason, Ohio) to automate its document management processes. The solution, which went live in October 2007, is integrated with the hospital's Affinity billing and registration system from QuadraMed (Reston, Va.).

Deploying a DMI system requires a hospital to examine both its internal processes and over arching document strategy. Providers should evaluate all paper-based processes, and develop a plan to ensure clinical staff will support the solution. “When a health system commits to doing this, it's committing to operational change,” Selman says.

Selman, as well as Dan Slates, director of IT at the Cleveland Clinic, both emphasize the importance of categorizing and standardizing document types across the enterprise, and properly indexing those documents within the DMI solution.

“Trying to define your document types across nine hospitals and coming up with a strategy that isn't too granular or not granular enough is difficult,” says Slates. “Some of our facilities have up to 2,500 unique document types integrated with the enterprise system. We're still trying to find the sweet spot for the number of unique document types that we should support.”

All stakeholders (including IT, clinical, and financial staff) should have a voice in selecting a solution, designing new work flows, and categorizing documents.

At ProMedica, Selman says physicians have supported the Streamline solution because it was intuitive, and provided them with valuable remote access to patient records. Sun Health tackled the physician adoption issue by taking an “all or nothing” approach to deployment, and focusing on the benefits. “We had to show the physicians what was in it for them,” Knight says. “They can log on remotely, and all records are always available to them. The time savings is unbelievable.” Knight also involved key physicians in the selection and deployment process, in addition to the senior leadership at the hospital.

While most of Sun's staff participated in group training sessions, Knight and her staff took a one-on-one approach with busy physicians. Knight also uses the internal messaging feature in ChartMaxx to send out weekly user tips so that physicians can get comfortable with the more advanced features of the system.

Hospitals also have to determine whether document scanning will be handled in a centralized or decentralized fashion, or even outsourced. Further, documents may be scanned before or after discharge, depending on the facility.

The time and resources needed to complete a DMI implementation will vary depending on the size of the hospital and the experience of the staff. The Cleveland Clinic was under pressure to deploy a solution quickly, but the process needed to be manageable. Working directly with Hyland, the Clinic deployed the solution for emergency department (ED) documents first, because they weren't computerized in any of the 10 hospitals.

The Clinic went live with the ED document at six hospitals in six months. Since then, Slates says his team has been working to integrate the DMI with the various ADT systems used at the hospitals, and the Lawson Software (St. Paul, Minn.) accounting system, even while they continue rolling out Epic.

Sun Health had an even shorter deadline; the hospital had to deploy ChartMaxx in just eight weeks. “We were able to do that, in part, because we already had the experience of using the previous system,” Knight says. We had automated our work flows, and had all of those processes in place.”

Keys to selection

Functionality varies among the DMI systems now available, but most hospitals are looking for standard capabilities like automated forms processing, indexing, document retrieval and distribution, and electronic signature.

Most hospitals ultimately select a solution based on the ability to integrate with their existing IT infrastructure, and references from other hospitals.

Sun Health chose ChartMaxx based on recommendations from some of its member physicians, who had used the system at a different hospital. The software also provided more robust integration, reporting and automated distribution capabilities than Sun's previous solution, Knight says.

Hyland Software's close relationship with Epic was key to The Cleveland Clinic's choice, but customer references also played a role. “I would talk to as many other sites as you could with similar systems in place before rolling this out,” says Slates. “The other key thing is to have the right stakeholders at the table, so you don't have to revisit any of your design decisions at later point.”

Slates adds that it's important to “future proof” the solution so that it can grow as more departments sign on. “On the IT side, build a system that is extremely scalable,” he says. “Document imaging is popular, and once people saw what it could do, I started getting two or three new requests per week. No matter what you estimate, this is going to be bigger than you thought.”