Steele, the CEO of SRSsoft, vendor of a hybrid document imaging and management/EHR system, had long touted the value of his product to scan paper documents, organize them in electronic files and make it easier for physicians to go electronic but retain their traditional practice patterns. "We had perfected document management," Steele asserts. "But we have had to spend an inordinate amount of development dollars and the lion share of our development budget creating a new data platform. We now have e-prescribing, vital signs, and order management data entered as discrete data." But even the new iteration of the SRSsoft EHR contains a document imaging and management module. "We will keep the document management module, absolutely," says Steele. "It is vital for every EHR vendor to have one."
The advent of meaningful use may well prove to be the watershed of EHR adoption in the United States. Many experts see the stimulus law as eventually pushing the industry away from document management systems-which are widely used in both hospitals and group practices. But even the most ardent proponents of structured data-the cornerstone of data mining and clinical decision support-concede that document management systems won't disappear any time soon in an information-saturated industry. Moreover, many providers who use document imaging technology in conjunction with their EHRs say they are well on the way to qualifying for meaningful use incentives.
That said, some physicians-who describe document management as a practical technology that solves key problems associated with the paper chart-blast the requirements of structured data as a meaningless use of their time. Even in the best-case scenarios, capturing structured data requires rethinking of workflows. And for some providers, neither discrete data nor scanned images are practical. They've partially reverted to paper.
Foundation for better care
Many proponents of structured data see it as laying the foundation for a better health care system, one in which clinical data is easily transported and mined. "Document management systems will play a much smaller role in the future," says Janie Tremlett, senior vice president, strategic and clinical services, for Concordant, an I.T. consulting shop that works with ambulatory practices. "We recommend that practices bite the bullet and develop an incremental strategy to enter patient data into the EHR and rely less on document management. They will see the benefits of doing that."
Other industry stakeholders describe document management technology as a short-term stopgap. Such systems constitute "thinking for today," says Justin Barnes, vice president of marketing for Greenway Medical Technologies, an ambulatory EHR vendor. "The future is in interoperability. You won't have a health care system built on document management systems, but we will have one built on interoperability."
The federal government is the 800-pound gorilla when it comes to promoting structured data. For vendors like Steele, the meaningful use program has diverted resources into tailoring a software package around federal requirements. "Being the largest payer, the government is driving what physicians should get in an EHR," he says. "It is a big change for us, and I say that with some sadness. We now have 21 out of 30 developers working on meaningful use certification. They used to be working on really cool things for doctors, but now we have to innovate to capture and share discrete data."
Future requirements
Other observers predict even more structured data requirements in future stages of the three-tiered meaningful use program (see box, page 42). "Structured data is a fundamental requirement of many core meaningful use criteria, and it is anticipated that future stages of meaningful use will rely on structured data even more heavily in the shift towards interoperability and coordinated care," says Claire Miley, a member of the health care practice of Bass, Berry, & Sims, a Nashville-based law firm.
Miley notes that the Centers for Medicare and Medicaid Services underscores the value of structured data as the prerequisite for many advanced EHR functionalities, such as clinical decision support need to improve quality, safety and efficiency. "The immediate push for innovation will likely be on the capture and exchange of structured data, a functionality that most document imaging systems currently do not have."
That doesn't mean that document imaging systems are necessarily headed for obsolescence in the world of healthcare providers, Miley notes. "CMS has recognized that there is a great deal of valuable health information that may never be able to be formatted, transmitted and automatically identified by an EHR system for integration into clinical records as structured data. Document imaging may play a vital role in the integration of existing medical records with newly emerging technologies and may serve to complement and enhance robust EHR technology by providing background, context and analysis not available in many structured data formats."
Federal policy aside, document management systems offer many practical benefits to providers. "Document management systems play a critical role in telling the patient's story," says Julie Dooling, professional practice resource manager at the American Health Information Management Association, a national member organization of health information managers. "Document management is the traditional place to start the journey to the EHR." Having scanned records, she says, enhances chart retrieval, thus facilitating workflows around chart completion and coding in the inpatient environment. In addition, scanning systems relieve the burden on HIM staff who must cope with an influx of "loose reports," or miscellaneous documentation that makes it way to the department after a patient has been discharged.
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