Lesson One: Some Records Are Destined to Remain in Paper
A 25-bed critical access facility, North Valley Hospital, Whitefish, Montana, lacks many of the resources that larger facilities may take for granted. Space for one thing. That's why, in 2006, when the hospital opened its new facility, it needed to figure out a way to retire its burgeoning medical records storage room. "Our new hospital had much less storage space for medical records," recalls Traci Waugh, director of HIM/compliance.
Like most hospitals, North Valley's documentation system had evolved into something that was neither fish nor fowl. Much of its clinical data was stored in a hospital information system from Westwood, Mass.-based Meditech Inc. that dated to the mid-90s. The Meditech system housed lab results, dictated reports and progress notes.
But a wide array of other clinical data, including that generated by the emergency department, remained mired in paper. "Even though we were partially computerized, the paper chart was our official record," Waugh recalls. At the end of each hospital stay, any Meditech data was printed out and combined with the other documents, such as physician orders, which originated as paper.
Hence the burgeoning file room.
To address the problem, North Valley Hospital turned to document imaging and management technology, which scans paper documents and then stores the images as digital files. North Valley considered some 10 vendors before settling on Alpharetta, Ga.-based HealthPort. Now, using the HealthPort technology, health information management staff scans any paper records at discharge. These image files are stored in HealthPort's repository. Other documents that originate in Meditech print directly to the HealthPort system.
Thus, HealthPort houses the hospital's official post-discharge medical record - and any originating paper files are subsequently destroyed.
It's a fairly simple set-up, one that is replicated in multiple hospitals nationwide. Documentation experts like Waugh say that the fully digital chart is still a worthwhile goal. It's one that many say they intend to accomplish.
Yet, attaining the vision is remarkably complicated - and expensive. That's why document imaging systems often play a key role in hospital operations. Faced with maintaining vast quantities of patient records, information managers know that those of paper origin are not likely to disappear soon. And even after scanning technology is installed, it's likely that many historical records will remain in paper form as well.
"We would have liked to back-scan all our charts," Waugh says. "But it was cost-prohibitive." That's why North Valley took the common step of only scanning current charts, leaving its file room intact and disposing of records only after the statute of limitations on record retention had been reached.
Until North Valley automates its ED, or implements computerized physician order entry, it's going to have a substantial flow of documents to run through the scanning system. Health care organizations also must cope with other paper documents that do not necessarily originate within their own four walls. "The prohibiting factor to having all digital data are things we cannot control," observes Andrew Cooper, I.T. manager at Zangmeister Center, a 16-physician oncology/hematology practice in Columbus, Ohio.
The center has been using an EHR, from Palo Alto, Calif.-based Varian Medical Systems, since 1998. The lion's share of its internal clinical data is digital. Yet, the group practice must cope with forms from other providers that are either paper in origin, or that defy an easy interface to its EHR. To append these paper forms to its EHR, Zangmeister Center uses a document imaging system from Madison, Ala.-based Cabinet NG Inc.
Cooper would prefer that data be fed digitally into its core EHR system, but for the time being, that is out of the question. "We can pull in data from hospital information systems and some labs," he says. "But other labs don't interface and end up in the document management system."
Clinicians access the Cabinet NG repository of scanned images through an application link in the EHR. The vendor's "retriever" icon sits atop the EHR. Clicking through to the Cabinet NG application automatically pulls up any scanned documents assigned to the same patient through a common billing number, Cooper explains. The document imaging software costs about $15,000 annually in maintenance and upgrade costs.
Lesson Two: Not All Electronic Workflows Are Valuable
Despite the hoopla around digital data, many provider organizations find that good, old-fashioned paper still works well, even better than an electronic counterpart. For these hospitals, the hybrid medical record is here to stay, as they pick and choose from the best of both the paper and digital worlds.
Despite having an EHR with comprehensive features, the Zangmeister Center, for example, still relies on what it calls "chart lite" during actual patient visits, says Cooper, the I.T. manager. During each visit, a condensed version of the patient's current chart is printed out for physicians. Its EHR has been running for more than a decade, but physicians still prefer glancing at a paper printout rather than squinting at the screen on one of the Tablet PCs the practice makes available. "We can do a lot with tablets and put data right in front of the physicians," Cooper says. "But nothing replaces pen and paper with physicians. I don't know how you get past that."
Physicians at Zangmeister do place chemotherapy and prescription orders electronically, however. The only paper involved is a short follow-up note that physicians hand write, providing instructions to medical assistants on how to proceed. "It is one of those procedural things that could probably be eliminated but works for our organization," Cooper acknowledges. The EHR, he explains, has electronic messaging capabilities, and the follow-up instructions could just as easily be dispatched through the computer. However, "walking down the hall and talking is more effective than messaging back and forth," Cooper says. "Physicians want to practice medicine, not instant messaging. They realize the limits of what technology can do for them." The follow-up instructions do make their way into the chart, however. After the visit, the forms are scanned with the group practice's document imaging system.
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