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.
“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.
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