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March 17, 2008

Going Digital
By Annie Macios
For The Record
Vol. 20 No.6 P. 20

Visit an Oregon radiology outfit that’s speeding toward the future in an effort to curtail paper use.

In any healthcare facility today, streamlining work processes and eliminating misplaced paperwork are always near the top of to-do lists. Finding the best way to make it happen, however, isn’t always the easiest task.

In a concerted decision to embark on digitizing nearly every aspect of its operations, Central Oregon Radiology Assoc., P.C. (CORA) in Bend, Ore., created a plan to achieve this significant goal. The initiative involves digitizing three key components that will be sequentially phased in and integrated: a digital document management system to store and manage consent forms, explanation of benefits (EOB) forms, and other documentation; a radiology information system (RIS) to manage appointment scheduling and billing; and a picture archiving and communication system (PACS) to store and manage radiological images, transcriptions, and medical information.

Marico Oliveira, CORA’s director of operations at the time of the decision and the current director of human resources, says the impetus to move toward a paperless environment came when the group went to a PACS environment for imaging. “Since we were in digital imaging now, we began to look at where we could reduce paper elsewhere,” she says. CPU Medical Management Systems, the facility’s RIS software provider, introduced Oliveira to Laserfiche, a document management solutions company it believed could help CORA reach its goal.

Making the Move
Oliveira learned about Laserfiche and the possibilities it creates at a CPU users’ conference. CPU found that many users wanted to integrate digital document management technology with their RIS application. In an effort to address this desire, it initially offered a basic version of a document imaging system. In the end, however, CPU believed Laserfiche could offer a greater amount of flexibility and options to not only meet but actually exceed customer expectations. As a result, the two formed a partnership.

“After seeing a demonstration of how much Laserfiche is capable of, we realized this would help us in our decision to go paperless,” says Oliveira. And because the RIS vendor and Laserfiche were partners, the availability of using the programs side by side eliminated the paper shuffle, she adds.

With the ultimate goal of integrating PACS, RIS, and its digital document management system, CORA has already seen substantial improvements since incorporating Laserfiche’s technology. Currently, CORA stores all medical images and related documents in PACS and uses Laserfiche for everything else, including exam orders, patient IDs, and insurance cards. Billing uses it to process insurance payments and to store and manage EOB forms, waivers, and other documents. Items such as board meeting minutes and human resources records can also be placed into the repository.

Getting the Records Straight
To begin the transition to a digital environment, human resources personnel were tasked with scanning in the old documents, which Oliveira says was handled in a methodical manner. “They were done by department, so we set a goal to get to a certain point by a certain date and just kept on track in completing the task in that way,” she says. Once all the records were accounted for and functional in the new system, old records were shredded.

“Rather than doing the scanning on the back end [for existing records], the goal is to have it all done on the front end as documents come in and are created. We are getting there, for example, with having the EOB and billing information in the system,” says Oliveira.
Components of an Integrated System

Mauricio Pinto, Laserfiche’s director for healthcare solutions, says streamlining document management and reducing the paper trail that pervades many healthcare facilities provide financial benefits. “When you minimize paper-based activity and work in a digital environment, you trim costs,” he says.

The application takes over after a scanner converts a document into an electronic image. More healthcare organizations are scanning today, but Pinto says the challenge is, “How do I store it securely, and how do I find it again when I want it? In fact, how do I find a phrase or single word in a large document?” To create an environment where data retrieval is simple, the solution needs more than a smart naming convention, he says.

Laserfiche’s product enables users to quickly locate documents, automates the information capture process, routes documents through an electronic workflow, and audits user activity. “All four of these specifications working in concert make a best-in-class document solution system,” says Pinto.

The repository provides a secure site to store and access documents, which users can organize in a way that meets the organization’s needs.

The ultimate goal in implementing an electronic document management solution is to quickly find records. Laserfiche’s technology extracts every word on a document and allows users to assign data fields to each record so it can be retrieved using a variety of search tools. For example, a facility such as CORA can search for a document based on the date of service, patient name, or a word related to the procedure that was completed. Advanced search capabilities include folder structure navigation in combination with full text search, template field search, and searches on known properties of the record. “Wildcarding” and “fuzzy” search capabilities offer the ability to search even if the user is unsure of the spelling of the search term.

Once the document is found, it can be routed using electronic workflow capabilities. At CORA, office staff can instantly scan insurance cards, create a folder for the patient, and generate the workflow, which routes the information to the billing department without ever having to manually move a file.

The auditing capability enables a user to choose a file or document and see everyone who has “touched” the case, which is beneficial for maintaining the continuity of care, as well as ensuring that business practice procedures such as billing are completed.

Regulating the Regulations
In today’s regulatory environment, it is critical to have a system that adheres to strict privacy and security guidelines, such as those mandated by HIPAA. At CORA, HIPAA and Joint Commission requirements are met through the installation of multiple levels of access control, including initial system access, controlling departmental silos, group or individual folder and records access, and field and word-level visibility.

“At our facility, HIPAA guidelines are conformed to by having appropriate levels of access in place. User rights and group rights were set up that protect access to folders and documents, which guard the integrity of the data,” says Oliveira.

Electronic redaction tools enable staff to obscure sensitive information, an especially useful feature when they need to send EOB forms, which typically contain information related to multiple patients, to a secondary payer.

Workflow Improvements
A proper solution for managing documents should offer an electronic replacement for manual processes, according to Pinto. Advanced workflow functionality securely routes records organizationwide and optionally alerts appropriate personnel if necessary. Staff can e-mail or fax from within the application and—if security permits—download records to CD, DVD, or USB drives. Electronic workflow can sequentially alert each staff member that work is waiting.

“When we went live, workflow improved tremendously,” says Oliveira. “Before when you needed a file, someone would have to manually retrieve it, and if more than one person needed access at the same time, it created problems. The change in workflow was substantial because we are no longer dealing with the manual processes. It also cuts down on lost or misfiled documents, which can consume a lot of extra time as well.” She adds that the users appreciate the system’s availability and ease of use.

Putting It All Together
When rolled out in a healthcare practice, document management technology can effectively streamline record management and reduce or eliminate paper when it is incorporated within the organization’s IT systems.

Nonclinical documentation, such as that related to insurance, scheduling, patient demographics, and, most importantly, billing, offers a multitude of opportunities for eliminating paper files. Essentially, all paper that comes from outside the organization, as well as internally generated documents, can be managed through a document management system.

For example, the billing department can instantly ascertain when the file is ready for coding, billing, and payment follow-up. “Checks are often received from a payer with a large batch of paper EOBs,” says Pinto. “With Laserfiche, those documents are scanned in and all text is extracted. This eliminates having to physically store the paper, and billing can simply search for a name or account number or date of service to locate a transaction.”

Coding Implications
“The coder serves a critical role in the billing process,” says Pinto. He notes that coders often work remotely, and with document management they can view the source documents in the repository via the Internet. They can code into either the billing application or the template fields, and the data are sent directly to the billing application, eliminating double entry and errors. Exceptions and charts with missing documentation can be flagged and routed to appropriate staff members for resolution.

Oliveira notes that CORA currently has five coders on site and has not yet integrated with the RIS. “We’re not yet at the point where the document imaging system streamlines the coding procedures, but in phase 2 of our implementation, instead of carting documents between facilities or departments, access will be simple. We could end up using coders remotely once the RIS portion is integrated,” she says.

In relation to transcription, she says at present it is done through CORA’s PACS rather than the RIS, so there have been no major effects or changes in workflow for the transcriptionists.

Ready, Set, Action!
Pinto explains that from front to back—when patients schedule an initial appointment to when they receive services to billing and collections—a document management system can serve as an electronic filing cabinet. While the RIS and PACS specifically manage clinical data, the system can be used in accounting, human resources, credentialing, and even maintenance. The ability to use the technology as a stand-alone process or integrated solution offers flexibility and room for growth.

When CORA integrates the document management technology into its RIS, Oliveira expects to reduce paper flow to a higher degree. “We are doing so much already in our initial phase, but we realize how much more Laserfiche is capable of and are looking forward to implementing the integration to take advantage of as much as possible. There is so much available, we have to implement it in phases,” she says.

Typical RIS integration starts with a real-time search for patients, either creating a file for new patients or retrieving current information for existing ones and populating index fields in processed records, which helps to avoid double entry and errors. Pinto says electronic document management technology is not simply about converting paper documents; it also stores and manages existing electronic files such as e-mails, wav files, JPEG files, and Office and Adobe documents that relate to a patient’s case. Further integration allows retrieval of stored documents from within the RIS application.

Although Oliveira realizes CORA will never be completely paperless, the move to digitizing operations will continue to streamline processes and offer further benefits as additional levels of implementation and integration are phased in.

“Interoperability, where the various departmental applications can talk to each other, is key in achieving the best efficiency and the greatest benefits to an entire operation,” says Pinto.

Oliveira agrees: “It’s time to take the next step. I’m very excited about it.”

— Annie Macios is a freelance writer based in Doylestown, Pa.

Applying Document Management Solutions Facilitywide
Any paper-intensive department—or any department striving to become paper free—can benefit from an electronic document management solution. With a stand-alone application, each department or functional area can establish its own secure records silo with unique folder structures, index templates, and user-defined workflow rules.
A good document management solution must do the following:

• Manage both paper and disparate electronic record formats.

• Normalize all records in a single, nonproprietary and nonalterable electronic record format such as TIFF.

• Extract and separately store data for searching.

• Store records in a secure repository that limits access by user and/or folder, document, and data field.

• Organize data in a way that suits the way your office works.

• Offer powerful search capabilities.

— Source: “Simplifying the Business of Healthcare,” Laserfiche Healthcare Focus Whitepaper, 2007

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