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The Role Document Management Will Play in EHRs
Health Data Management Magazine, August 1, 2008
Early this year, The Cleveland Clinic started capturing images of electrocardiograms in its document imaging and management system’s data repository and making the images available to clinicians via the clinic’s electronic health records system.
The MUSEC cardiology information system from GE Healthcare, Waukesha, Wis., produces a PDF file of the EKG images, saves it in the OnBase document management system from Westlake, Ohio-based Hyland Software Inc., and displays it through the EHR of Epic Systems Corp., Madison, Wis. The EKG’s order in the Epic records software includes a hypertext link to the PDF file.
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“Not only does the PDF show up in the link to the order, but also in physicians’ in-baskets, so they don’t have to go looking for it,” says Dan Slates, director of integrated enterprise applications at The Cleveland Clinic.
The clinic this year also started capturing clinical retina images, storing them in the OnBase repository and making them accessible via the EHR. “The end user doesn’t really know they’ve left Epic to view the images,” Slates notes. “That’s nice because it doesn’t take them out of their EHR experience.”
Document management technology may seem somewhat old-fashioned compared with sophisticated electronic health records systems. But the well-established technology has brought some degree of clinical automation to many provider organizations long before EHRs. Users are finding the technology can substantially augment the capabilities of an EHR by digitizing paper documents and other data so that they can be stored in a data repository accessible via the EHR. Because of easier integration, some providers also use a repository to store electronic data from patient monitors and other devices, also viewable from the EHR.
For some users, such as The Bone & Joint Clinic in Franklin, Tenn., the document management system is the EHR. And it’s going to stay that way for some time, says Lisa Raines, CEO.
“We’ve not seen any products that we like better,” she contends. “Unless some brand new product comes along, I see no reason to change what we’re doing.” And document management backers don’t expect the technology to become obsolete anytime soon.
“We’d love to be paperless, but the reality is we’ll never be 100% electronic,” says Jenny Clyatt, administrative director of health informatics and technology at Proctor Hospital, Peoria, Ill. “Patients will come in with paper documents from elsewhere.”
The Missing Piece
Implementing document management software last October “was the last piece of the puzzle to make our electronic record whole,” says Michael Putkovich, a director of health information management at Spectrum Health Hospitals in Grand Rapids, Mich.
An intelligent document classification application from Irvine, Calif.-based Kofax Inc. is used with a document imaging system from Kansas City, Mo.-based Cerner Corp., as well as the vendor’s Millennium clinical information system used at Butterworth, Blodgett and DeVos Children’s Hospitals and related ambulatory surgery centers.
Kofax’s document classification application uses optical character recognition technology, enabling the vendor to program the system to recognize documents that do not have a bar code. All forms, including bar coded ones, also have a form title as a second level of classification.
Consequently, all scanned documents or inputted data are automatically filed in certain “buckets,” or event set codes.
Before Spectrum Health adopted document imaging, it had 1,400 paper forms. Those forms and the discrete data now are organized in 70 buckets.
While providers often store digitized documents in a repository that’s viewable via the EHR, Spectrum is hosting all patient information—discrete data elements and scanned documents—in the Millennium clinical system.
“Our goal is to have Cerner be the source of truth for all clinical documentation,” Putkovich says.
This way, he adds, a physician can look in one place for a patient’s history and physical data, and not have to remember if the information was handwritten or entered into the EHR.
“The right data must be available at the right time to deliver the highest quality care,” he notes. “That’s the real power of scanning directly into Cerner.”
Because Spectrum Health had used Cerner’s Millennium system since 2001, Putkovich had assumed that clinicians would be able to easily navigate the EHR to locate the newly scanned documents. The key was to give physicians one place—Millennium—to find all clinical information, he believed.
Putkovich soon learned, however, that many clinicians were not as computer savvy as he had anticipated when it came to navigating through the EHR. That upset some clinicians, which put document imaging in somewhat of a bad light, he recalls.
“Take a good assessment of your clinical staff’s computer literacy skills,” he advises. “I would have changed how we trained physicians, so when we started to take their paper world away, they would be able to find the clinical data that they needed in an easy manner.”
Being able to automatically classify scanned documents and place them in the appropriate bucket, regardless of whether they were bar coded, was high on Putkovich’s wish list when looking for a document classification vendor.
Now, he’d like to see the vendors take document classification to the next level by creating an easy way to automatically index certain documents. For instance, a two-sided progress note might include observations for a five-day period. “But when you scan, there’s no way to automatically index the document to show the note contains data from January 1-5,” he adds. “So, we have no choice but to manually index these types of documents.”
Removing Obstacles
Proctor Hospital’s document management vendor also trains its software to recognize and classify different types of documents. That removed a major barrier to actually adopting electronic records at the 163-bed hospital, says Clyatt, the administrative director of health informatics and technology.
The hospital expects to have its Horizon EHR from San Francisco-based McKesson Corp. fully implemented next year and integrated with its document management system from SolCom Inc., Sioux Falls, S.D.
Having the SolCom system recognize forms—such as lab results, advanced directives and discharge summaries from a transferring facility—has helped ease migration to the clinical system, Clyatt says. That’s because hospital staff members don’t have to manually identify all forms that are scanned and affix a bar code to them. Nor will the hospital have to redesign all of its various forms, which would have taken 18 months.
“We sent SolCom all our form types and they trained the system to recognize specific Proctor documents,” Clyatt says.
Having the documents automatically recognized also automates and enhances workflow across the facility, says Angie Markum, business analyst/informatics specialist at Proctor. Different documents in a patient’s chart can be sent to different workbaskets, such as one for coding.
“We can automatically put 30 charts in a workbasket for review by quality assurance and utilization review staff,” Clyatt adds. “Nurse managers can review charts on demand rather than wait one to two weeks for them.”
With automated workflow comes increased employee satisfaction. “As a culture, we’ve all gotten used to quick turnaround times for getting access to our money or our food,” Clyatt notes. “This gives us self-service. When I want it, it’s there for me rather than waiting on someone else.”
Scanning paper documents to make them available via the EHR also will improve the quality of care because that information can be available more quickly, Clyatt says.
The hospital is considering putting small scanners in each clinical area so clinicians can have all pertinent information electronically available at the point of care. “We need to get to a point where all information is available to clinicians whether they are at the hospital or at remote locations,” she adds.
First Step to EHR
Providing remote physician access to patient data via a secure Web portal is one of the features of the document management system at Warren Hospital in Phillipsburg, N.J. Physicians can electronically sign their documents whether at the hospital, office or home.
The 214-bed hospital has phased in the ChartScan and ChartView products of SoftMed Systems, which now is part of 3M Health Information Systems, Salt Lake City.
Warren Hospital sees document management as a first-generation electronic health records system, says Debbie Bowlby, director of information systems.
An interface with its Invision hospital information system from Malvern, Pa.-based Siemens Healthcare enables access to a wide range of data from 3M’s system.
Documents scanned into the repository and viewable from Invision include face sheets, lab and radiology results, and transcribed documents, with nursing documentation coming later this year.
In the early stages of implementation back in 2004 and 2005, the focus was on gathering documents for forms generation and back-scanning.
Then, a major regulatory change affecting the chemotherapy department, which moved billing from monthly to daily, taught the implementation team the value of workflow, Bowlby says.
“We should have spent more time looking at the processes,” she recalls. “But the product was new, and you don’t know everything you should be looking at.”
Implementers had to really understand workflow because the chemotherapy department had to completely change its billing processes. “The implementation of other departments went easier,” she adds.
Warren Hospital doesn’t have a timeline for implementing a full EHR. “We are planning that this software progresses to turn into a form of an EHR,” Bowlby says.
But for that to happen, vendors have to get a lot better at integration, she contends.
Bowlby, for instance, doesn’t just want to pull data from Invision or other systems into the ChartView document management system. She also wants to be able to send information back from ChartView to other applications. “I would also like to see a better way of interfacing,” she adds.
Who Needs an EHR?
Some organizations already have concluded that they can do just fine without an EHR.
The Bone & Joint Clinic in Franklin, Tenn., went paperless without an EHR by using a document management system from Cabinet NG Inc., Madison, Ala. Staff members at the 13-physician clinic no longer permanently document anything on paper, says CEO Lisa Raines.
Laboratory and radiology reports, patient follow-up forms, and anything else that comes into the clinic on paper or is generated in the clinic is scanned, digitized and placed in a data repository that acts as the clinic’s EHR. Physicians’ dictated notes are transcribed into a computer file, viewed and signed online, and placed in the repository.
“If it was historically on paper, we have it electronically,” Raines says.
But the document management system does more than store digitized paper documents. More than four years ago, the clinic started to store in its repository digital images of endoscopic pictures taken during surgery.
The photos, taken by a tiny camera inside the body, are fed to a processor and then sent to the data repository. “I pull an imaging card out of the camera processor, put it in the computer and download the electronic file to the repository,” says Brian Lewis, director at the clinic’s surgery center.
The process is fairly simple and fast, considering the size of the image files. “I can download about 10 pictures in seven minutes,” Lewis says. “Today, I downloaded 37 from the past two days in about 25 minutes. I just start the downloading and do something else until it is done.”
Further, the quality of the pictures is exceptional, Lewis adds. “If the computer screen is HD, you’re looking at an HD picture.”
The clinic also has seen savings because it no longer buys photo paper and other supplies at a cost of about $250 for 100 photos.
New Functions
A decade after installing the document management system, The Bone & Joint Clinic still is finding new uses for the technology.
The practice this year automated its processes for managing and dispensing durable medical equipment, such as splints and braces. Using wireless, hand-held computing devices, staff members scan the equipment’s bar code, sign an acknowledgement document that appears on the screen, and transmit the document to the document management system’s data repository. A program written by the vendor, Cabinet NG, automatically updates the DME inventory and prints a charge ticket for manual input into the practice management system.
This new function of the document management system, which cost $20,000, brought immediate benefits, says Raines, the CEO. “We save money on manual versus electronic processes daily,” she notes. “We no longer have to scan any DME documents because they move electronically. We no longer have to manually track inventory. It’s all labor savings.”
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