But in the next breath, Kohn emphasizes a point that many in the industry are still in denial about: While scanning documents and making them available as electronic images may not fulfill the holy grail of the EHR-namely digital, discrete data-the practice is not likely to disappear anytime soon. And in fact, the advent of the EHR may spur even more need for document management systems. "It is about time CIOs learn that discrete data is not the only thing they will be collecting, exchanging, and reporting. There are many uses for document managements systems-they won't go away."
Indeed, document management systems serve a variety of functions in the industry. For many organizations, they are a transitional bridge to an EHR. And even for organizations with a "full" EHR, they serve as a data archive of paper documents generated outside the hospital. Some providers have found utility in deploying document management systems in highly specialized ways in departments whose needs might not be met by any conventional EHR or practice management system. Finally, organizations with more advanced document systems use them to enable certain transactional functions, such as electronic signatures for incomplete charts, or as part of messaging systems for clinicians.
Despite its value, document management technology has decided limitations, and even its champions envision a day when its value will be marginal. A scanned file of a progress note may be "electronic," but its contents are usually not searchable in any meaningful way, nor do files in document management systems lend themselves to quality analytics or reporting-two of the cornerstones of pay-for-performance and quality initiatives from federal and commercial payers. Sophisticated document imaging systems work in close tandem with an EHR, but many systems do not-a limitation often cited in discussions of the two technologies.
Long-term contract
The sheer volume of documents in play in the health care setting-many of which are beyond the reach of even the most functional EHRs-suggest longevity for document management vendors. In 2009, 246-bed St. Anthony's Memorial Hospital, Effingham, Ill., scanned nearly 600,000 documents totaling over 1.1 million pages, attests Terri Phillips, manager, health information. For large health systems, the issue compounds. Across its nine hospitals in the Kansas City area, St. Luke's Health System scans some 19.5 million pages annually, says Sharon Korzdorfer, director of health information management (see sidebar, page 40).
Both organizations have EHR initiatives underway. And they underscore a key trend in the industry: the pathway to digital data is a long one, and a document management system can provide relief from paper documents along the way.
St. Anthony's, for example, implemented a document management system, from St. Paul, Minn.-based 3M Corp., in 2005 with the goal of providing clinicians an easily accessible version of its paper-based, post-discharge inpatient record. Two years after it introduced the document management system, St. Anthony's deployed a new clinical information system, from Meditech.
However, the hospital still wanted to maintain the convenience of the centralized record offered by the 3M set-up. "We knew it would be a long transition period to getting a fully functional EHR," says Phillips. "We still have handwritten documents and other documents, like EKG printouts, that are not interfaced anywhere, and are now being printed and scanned. We wanted the physician to see the medical record from anywhere, and now they can see the entire historical record." St. Anthony's document imaging system now serves as its "legal EHR." (see sidebar, page 38)
Lowering expectations
Some health systems eyeing enterprise EHRs recognize that the health care ecosystem still relies heavily on paper, and therefore lower their expectations from the get-go about the amount of data they will be able to create, capture and store digitally.
Consider St. Louis-based SSM Health Care, a 16-hospital system that is partway through a massive deployment of an EHR, from Epic Systems, Verona, Wis., that began in 2008. The goal is a standardized clinical record across the enterprise. Through June, SSM had completed the deployment at nine hospitals, and was on target to complete the effort, "Project Beacon," in 2014. It is rolling out the new EHR hospital by hospital-while at the same time implementing a document management system from Westlake, Ohio-based Hyland Software, designed to work in tandem with the Epic system. "It is a complete cultural change," says Lilley Hammock, clinical transformation manager.
Prior to Project Beacon, SSM maintained a hybrid chart, using a legacy McKesson system for patient registration and certain financial applications, paper for most clinical documentation, and a few best-of-breed systems scattered in ancillary departments, such as anesthesia. Eventually, SSM will replace the legacy McKesson systems with an integrated clinical/financial suite from Epic, but it has opted to put in the clinical side first. It will scan documents from its old financial system, making them available to users at a hospital deploying the new clinical system. Likewise, it will scan any documentation from its anesthesia system until it gets replaced by its modern Epic counterpart.
Training on the various systems has been the big challenge, says Amanda Blase, team leader, health information management. "We are training on Epic and also on Hyland," she says. "Meanwhile, employees are required to keep working in the paper system they were used to. Time management is the issue." The Epic software is closely integrated with the Hyland scanning module, which makes it easier to adjust to a new workflow, adds Hammock.
Transitional bridge
In addition to serving as a transitional bridge to the EHR, a document management system can provide a type of electronic storage cabinet for the multitude of documents generated outside the walls of a provider organization, but which nevertheless support important clinical decision-making. Zangmeister Center, a 16-physician hematology/oncology practice in Columbus, Ohio, introduced a specialty EHR, from Varian Medical Systems, over a decade ago.
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