Paper Trails

Nov. 15, 2011
As the HITECH Act slowly begins to move the market, a large number of hospitals are expected to adopt electronic records as part of the drive toward a paperless environment.
Mike Davis

As the HITECH Act slowly begins to move the market, a large number of hospitals are expected to adopt electronic records as part of the drive toward a paperless environment. But, as many CIOs can attest, the process of going digital can be complicated. As a result, organizations are turning to content management solutions to help ease the transition by incorporating paper documents into the patient record and creating a centralized data source.

And while some view document management as a temporary fix that offers little in the way of data analysis, Mike Davis, executive vice president at Chicago-based HIMSS Analytics, believes it serves a key purpose for organizations in limbo, and may continue to have a market presence for some time. “I think that everyone will need document management capabilities to some degree,” he says. “You just can't get to a paperless environment unless you have that.”

Suresh Gunasekaran

Davis cites three primary functions for document management and imaging in the hospital setting: revenue cycle management, human resources, and information management. For many organizations, the starting point is in the administrative and billing departments.

At the University of Texas Southwestern Medical Center in Dallas, Hyland Software's (Westlake, Ohio) OnBase content management is used to scan insurance cards, patient consent forms, and explanation of benefit forms from insurance providers (to attach to patient records). According to Suresh Gunasekaran, assistant vice president and CIO, University Hospitals and Clinics, it can help provide a sense balance in an environment that is very much in flux. “I think the industry's made a lot of progress with making many billing functions electronic, but we still get 500-page documents from our payers, and parsing all of that electronically and posting it is difficult,” he says. “Document management is a stop-gap for that.”

While CMS has implemented e-billing, and a number of payers are starting to adopt an electronic standard, Gunasekaran says he believes it will still take several years for the change to take effect. So until there is an industry-standard insurance card, he says his organization will continue to leverage document and image management.

At BryanLGH Health System, a 583-bed medical center based in Lincoln, Neb., Mason, Ohio-based MedPlus' ChartMaxx electronic file cabinet functionality is being used to manage claims and billing information generated by third parties. “Instead of producing it back on paper, we just send the forms through ChartMaxx,” says CIO Rich Marreel. “That way, the billing department is able to just bring up the patient record online as opposed to fumbling through papers.”

Denni McColm

After it was deployed in the billing department, the solution was extended to other areas including human resources, where workers scan and store employee files. Marreel says it's also used across two BryanLGH campuses as the electronic patient record solution. “The idea is anything that's needed for reference that has a substantial impact on the operations of the organization is information we want to get in electronically.”

The patchwork EMR

While document management plays a key role in linking administrative files, perhaps its most significant function - particularly in the current environment - is to integrate data into the hospital's electronic record, says Davis. “As hospitals move toward an EMR, what they're trying to do is gather as much discrete data as they can. With discreet data, you can analyze it more effectively, and you can use it with clinical decision support systems, which will become increasingly important.”

For many hospitals, most of the data that needs to be scanned and indexed into the patient record comes in the form of laboratory results and referral information. This is particularly true at academic medical centers such as UT Southwestern, where patients often go seeking second opinions - and bringing with them data from outside providers.

“For us, document imaging bridges our gap with the outside world,” says Gunasekaran, adding that many insurance companies require labs to be done through companies like Quest Diagnostics (Madison, N.J.) or LabCorp (Burlington, N.C.), which don't always have adequate interfaces with providers. “As long as we have outside labs and outside providers of ancillary services, we're always going to need some way to scan things in. Because it's unacceptable for us to have 85 percent of the information in the EMR and 15 percent of it somewhere else,” he says.

What some organizations are finding is that even if they are fully integrated, content management still needs to be part of the strategy. Citizens Memorial Healthcare, a Bolivar, Mo.-based system that includes a 74-bed hospital along with more than 500 long-term care beds and 20 physician practices, is about as close to paperless as an organization can get, according to CIO Denni McColm. But as she says, that doesn't stop paper from coming in - particularly in the outpatient setting. “Every referral out to a subspecialist generates paper back to the practice.”

And while there are fewer documents flowing into the hospital than the physician practice, the strategy is the same in both settings. “Our philosophy is to get everything electronic that you possibly can, and then scan whatever is left,” she says (see sidebar for more information).

The problem with this, however, is that data from scanned documents and images, while accessible, may not always be usable - particularly when it comes to lab results. When an interface is set up with a lab provider at UT Southwestern, clinicians are able to sift through data and normalize the reference ranges (which can vary due to a number of factors, including use of different instrumentation), according to G licated when PDFs are involved. And while discreet data values can graph automatically in the EMR system, lab results that are scanned cannot, meaning clinicians have to open each individual picture in order to view data.

This, says Davis, is where it gets tricky. “The challenge for hospitals is to try to figure out how much of the data needs to be discreet, and how much of it is okay to be in document images, or text blocks created from dictation transcription,” he says. And as health IT legislation moves forward, the issue will only intensify. “A lot of what's in ARRA HITECH is the ability to report information to show that you are getting favorable outcomes, or that you're doing the appropriate procedures. And I think as we move into that, it's going to be very important to have these capabilities.”

Another sticking point many organizations have encountered with content management is in filing and indexing scanned documents to ensure they are easily accessible. “It's been a big challenge for us,” says McColm. “How discreet do you try to make the document? If you scan a lab result that comes in from another provider, do you treat that as a lab result or as a CBC (complete blood count)? And if you get a referral letter back, do you file it as a letter, a referral or a report? There's so much room for error.”

The hope, she says, is that outside organizations will soon be able to manage reports in an electronic format. In the meantime, Citizens is developing a more centralized procedure for filing documents.

UT Southwestern has experienced similar problems with scanning, a process that “really puts a lot of pressure on people to name things and scan them into the right place,” says Gunasekaran. “The scanning bucket always ends up feeling a little bit too cluttered because of everything that's scanned goes in there, whether it's a lab for cholesterol or a lab for a nuclear medicine test. Whereas in the EMR, everything has its own orderly place.”

But while document and imaging management may not be the perfect solution, for many CIOs, it still beats paper. And until true interoperability exists among healthcare systems, it will continue to serve a key purpose.

“Document management systems, in my opinion, will always be required to some degree, because there are forms out there like consent forms that are always going to have to be scanned in and capture-retained as part of the medical record,” says McColm. “The challenge, going forward, will be to determine what information we need to get in discreet format as data, and what information is okay to scan as a document and create as an image.”

Healthcare Informatics 2009 October;26(10):23-30

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