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March 22, 2004

Scanning the Backfile: Finding a Solution That Fits
By Margaret Castrey

Every HIM director understands the benefits of document imaging, the process of scanning archived paper documents to support a robust electronic medical record (EMR). The challenge remains how to get it done.

Both in-house and outsourced options are worth investigating, and both avenues require the HIM director to get answers to many questions. Equipment vendors––and scanning vendors––vary in ability, quality, and service. In this article, HIM directors and industry experts offer advice to help you decide whether in-house or outsourced scanning is your best option and suggest steps for finding a scanning vendor that will make your life easier.

In-House vs. Outsourcing: How to Choose
Organizations differ in their available staffing, resources, and goals. Last summer, an American Health Information Management Association (AHIMA) study group examined the broad issue of electronic document management. The volunteers identified four general combinations of in-house and outsourced services to consider. The first three require dedicating space in-house, the first two require purchasing and maintaining equipment, and the first requires hiring more full-time employees (FTEs). Only the fourth option relieves the HIM department of all three burdens.

1. Purchase an in-house system and direct your staff in on-site conversion.
2. Purchase an in-house system and direct a vendor’s staff in doing the preparation, scanning, and indexing on-site.
3. Contract with a vendor to operate their system, using their staff at your site.
4. Send your records for off-site conversion with documents available via the Web, intranet, and CD.

“I like outsourcing,” says Mary Mike Pavoni, MS, RHIA, FAHIMA, a West-chester, Ill., consultant who provides interim and project management services for hospitals. “It allows me to send the work out to a reliable vendor with a proven track record. Some hospitals want to operate an imaging center like the old print shop, but right now I don’t think it’s cost-effective. You have to focus on your core business and consider the costs of adding more FTEs, equipment, software, and space.”

What Business Are You In?
Early in the decision process, ask yourself two basic business questions: What’s my core business, and what are my strengths? Also, consider the specific issues you will encounter. Are you prepared to increase the FTEs you must hire and supervise? Can your facility handle the personnel and equipment needed for an imaging environment? Will your network infrastructure handle images and data flowing at the same time? Are your servers compatible with the scanning equipment? Will your vendor integrate the products or equipment into your operation or will you have to do that yourself?

What Equipment Should You Purchase?
You will need to determine the volume of your scanning and its duration. For example, scanning the backfile would involve millions of images. However, ongoing, day-forward scanning volume would be much smaller, particularly as more information is generated electronically and automatically fed into the system.

“If your purpose in scanning is primarily to make archived records more accessible, you shouldn’t buy expensive high-speed scanners,” says Rob Rodriguez, business development manager for healthcare and hospital markets, Imaging Business Machines LLC, Birmingham, Ala. “The archive is a one-time volume. Equipment quickly becomes outdated, and a used machine will have a low resale value.” Also, remember that buying a lower-end scanner may saddle your department with continual quality, performance, and maintenance issues.

If you do opt to buy hardware, does the vendor have 24 hours a day, seven days a week coverage and people nearby who can fix it? Will you get automatic software upgrades? If not, will your system still be compatible with other software in the hospital, such as the operating system, databases, and network? Most information technology departments constantly update their software. How will this affect your equipment, access to databases and network servers, and the images and indexes you produce?

Ability to adapt to change is another issue, so get out your crystal ball. What if you want to start putting records on CDs or the Web? How easily would you be able to change from bitonal to color? Would you need new equipment? If you switch from using patch codes to bar codes to separate documents, you will have both for a period of time. Will your equipment adapt?

These and other questions deter most HIM directors from attempting to scan archived records in-house. In fact, some hospitals have been disappointed with their efforts to use existing staff for in-house scanning. The HIM department at Missouri Baptist Hospital-Sullivan bought a scanner a few years ago. Medical Records Manager Dawn Falloon says the department started scanning the files of expired patients, but discovered it would need a high-volume scanner and one FTE dedicated to scanning to keep up.
Falloon decided instead to return to outsourcing. Although it will be several years before this rural facility has an EMR, working with a good vendor has enabled them to take an important step in electronic access to records.

Scanning Vendors Relieve Crunch
Oklahoma’s Duncan Regional Hospital was recently listed as one of the 100 most-wired hospitals by Hospitals and Health Networks magazine—quite an accomplishment for a 148-bed rural facility. Presently, 90% of its medical records are housed in their health information system (HIS), according to HIM Director Nancy Lott, RHIA. Lacking that other 10%, however, means it still prints everything and the paper file is the designated legal record. That will be true until the hospital has completed all testing and quality assurance to confirm that the EMR is complete—a task Lott hopes will happen this year. This spring, the department begins day-forward scanning in-house.

Last year, Lott opted to begin preparing the archive for the EMR by converting the 2002 emergency department and outpatient records to images on CDs instead of film. Choosing her scanning vendor was easy, Lott says, because she had a healthy relationship with EDCO—The Document People, a national provider of document management services, when she worked at other facilities.

The timeline for EMR implementation is shorter at Duncan Regional than at Clinton Memorial Hospital (CMH) Regional Health System in Wilmington, Ohio. “Many pieces of the health record are generated electronically, but they are housed in separate systems,” says CMH Medical Records Director Suzanne Samarghandi, RHIA. “Our strategic plan calls for having everything integrated into a single system within five to seven years.” Her plate is already more than full, so she sought a scanning vendor who could quickly convert their backfile to an electronic format.

Her most important selection criterion was experience with medical records. “We have hundreds of different forms and handwritten progress notes,” she explains. “Especially for the inpatient records, I didn’t feel comfortable going with a company whose expertise was in business or human resources files.”

Other factors she considered included number of years in business, record pickup services, and turnaround time. Personal factors also came into play. “Some vendors were just too pushy,” she recalls. “I could tell that for some, doing the imaging was the least of their concerns. They just wanted it as a foot in the door, but the scanning was all I wanted to deal with at the time.” To keep vendor representatives from overwhelming her with technical issues, Samarghandi found it helpful to have an IT person attend the vendor meetings to assist her.

When Sue Stinson’s HIM director was trying to decide what to do with the archived records at Mary Greeley Medical Center in Ames, Iowa, Stinson’s input as operations manager was straightforward: “You can’t hire enough people in-house to get this done.” Her priority need for space made outsourcing the correct choice. Now medical records supervisor, Stinson is satisfied with their progress toward a complete electronic record and glad that they hired a conversion company to box up their oldest backlog and drive it away.

The HIM department at Halifax Regional Medical Center in Roanoke Rapids, N.C., made a similar decision in not purchasing a scanner or hiring more FTEs. Instead, it reassigned its filming budget to scanning. Now, retrieval is much faster, easier, and user-friendly, says Medical Records Manager Mary Thompson, RHIA. The records on compact discs are indexed in a single database, which tells them immediately which CD to pull.

Budget Influences Decision
“If outsourcing the scanning had cost much more than our filming budget, we might have more seriously considered setting up scanning in-house,” says Mark Ebert, MD, managing partner of Stillwater (Okla.) Women’s Clinic. Although it was briefly considered, this independent practice of four OB/GYNs had no space to spare, nor did it want to add equipment and personnel.

Ebert’s clinic had a solid, longstanding relationship with its vendor, which formed an important basis of trust. Although the practice had previously kept roughly five years in paper, the painless transition and convenience of the new archive system may persuade it to scan more years. “The copies we get from the CDs are 1,000% better than what we got from film,” Ebert says.

Ebert suggests that those who are apprehensive about converting images onto CDs request a demonstration at their facility and visit a site that is already using the technology. Vendors will be pleased to arrange such visits, but potential clients should make sure to get a private conference without the vendor present. That way, they can ask about any problems and how the vendor resolved them.

Access to records was the driving force at Halifax Regional. “We are migrating in a slow fashion,” says Thompson. This small rural hospital is in the process of purchasing a new health information system (HIS), but it needed to resolve space and access problems in the backfile right away. “It was getting to be a nightmare, searching through five bookcases loaded with piles and stacks of loose outpatient and emergency department records we didn’t have time to integrate,” Thompson says. Outsourcing was the practical option.

From approval of the sample to receipt of the first finished CDs took approximately four weeks, she notes. Then, the department received weekly shipments until the conversion was complete. Scanning two years of outpatient and emergency records eased the space crunch for the moment. When the HIS is ready, the last scanning project will be the current paper inpatient records, which will bring the EMR up-to-date.

Amazing Scanner Technologies
High-end production equipment uses optical character recognition (OCR) during scanning, according to EDCO’s Imaging Manager Bob Barnum. The equipment automatically picks up important data that populate eight to 10 indexing fields, including dates, names, bar code information, and even form type so the visual background can be dropped out to reduce file size.

“File size is a critical issue when you’re storing millions of images,” Barnum says. “That’s why our scanners make two different images of each side of the document at a single pass.” The 200-dots per inch (dpi) images go to the CD for long-term storage because it takes up less space on a hard drive. The 300-dpi images give greater accuracy when run through an OCR. The software then matches the image with identifiers from the hospital’s master patient index. After a quality inspector verifies accuracy, the 300-dpi versions are automatically discarded.

The technology today is phenomenal, Barnum says. “Our high-speed, high-volume scanners can create 10 different image types automatically,” he says. “They can eliminate color from forms, straighten an image, eliminate borders, and do other cleanup for better appearance and smaller file size. They even have diagnostics that evaluate if quality is consistent for every document.”

Setting Up a Test Sample
To find out which vendor is your best match, “make them prove they can do it,” Rodriguez says. “Create a sample of your ugliest work so you can see their output.” If you’re looking at buying equipment, volume is definitely an issue. If your daily workload will be 10,000 images, a single box would not be a fair test. “It shouldn’t be a quiz; it should be a real test,” Rodriguez emphasizes, encouraging HIM directors to negotiate for the largest sample possible.

“A test sample benefits hospital and vendor alike,” Pavoni points out. “It will reveal if the filing is bad and if loose sheets have been properly placed.” Also, make sure all vendors visit on-site and do their own pricing assessments, she says. That way, they cannot later say that added preparation services are needed, which will boost the price. To verify quality, have a quality assurance person scrutinize every image in the sample.

Investigate All Options
“When a hospital seeks to make the archive accessible to the HIS, the biggest problems we see are ‘legacy’ issues,” says Jim Wanner, CEO of KeyMark, Inc., a hospital systems integrator in Greenville, S.C. “Most people are so hung up on sticking with the vendor of their HIS system that they don’t seriously investigate other options that often work better.” Wanner calls it the “Same Vendor Means Security” mind-set. In reality, though, it might cost the facility four or five times less to integrate another system than to customize the initial application. For example, it can be simplest to outsource the scanning, store the images, index on a dedicated system, and tie that to the HIS.

That is what the information system staff at Valley View Regional Hospital in Ada, Okla., has done. It loads the CDs onto a dedicated hard drive that shows up as an icon on the HIS screen. The HIM department can search by name or medical record number using software and print on a desktop printer.

Implementing the EMR system at Valley View has been a slow process for Director of Health Information Linda Vires, RHIA. At this rural hospital, the EMR system has been in place for a year and a half, but they are still trying to work out the bugs. Until the staff gains confidence in the stability and reliability of the system, it will continue to print all records in their entirety.

Vires used to keep five years of records in hard copy, but the growth of computerized nursing notes created some very fat charts. This precipitated a space crisis. “I had stacks of charts 4 feet high under and around almost every desk,” Vires says. “We had to do something fast.” Having a responsive and reliable conversion vendor was worth gold in this case because the company responded quickly with a mass purge and delivered the scanned images on CDs.

The system has been trouble-free and easy to use, Vires says, and as long as the volume of paper to be scanned remains high, she will continue to outsource the task. Valley View has implemented a “paper reduction task force” that has taken on the chore of weaning the staff off paper gradually, one unit at a time, in hopes of reducing printing enough to bring the scanning in-house within approximately five years.

Lott has also adopted a dedicated hard-drive strategy. By keeping the images and index on their own server, Lott avoids having to go in and customize the indexing to fit the HIS system. “My staff easily pulls up patients on the screen and sends a range of pages to print on regular paper, using an existing PC and printer,” she notes. When they roll out the complete EMR, she’ll get a network license so everyone in the department can access the images.

Scanning: Here to Stay?
“Most hospitals are in a hybrid state today,” says Michelle Dougherty, AHIMA’s professional practice manager. “They get patient information in electronic, filmed, and paper formats. A growing number of hospitals are using document imaging technology to convert paper records into electronic images.” Of course, the quantity of paper will diminish over time as more records are generated electronically, she says, but some level of paper is likely to stay for years to come.

That means scanning is here to stay as well. “It is an integral part of the larger function called electronic document management,” Dougherty says. The AHIMA has provided a great deal of information through its eHIM initiative to help directors get a grip on this complex area. “It’s up to us to take on this leadership role,” Pavoni says. “Scanning is the bridge to the electronic health record—and a relatively inexpensive one at that.”

— Margaret Castrey is a freelance writer and healthcare consultant in Springfield, Mo.

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