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April 30, 2007
Lacking the pizzazz of other so-called cutting-edge technologies, document imaging nevertheless gets the job done when it comes to digitizing paper records. An often-overlooked component of an electronic medical record (EMR) project, document imaging nevertheless plays a leading role in the process. The ability to scan patient information that can be viewed in an electronic environment cannot be underestimated. It helps eliminate overflowing filing cabinets, supports easy electronic patient record retrieval, and eases HIPAA-compliance concerns. According to Brett Griffith, president of Alpha Systems, document imaging offers instant access to previously paper-based documents, eliminates paper, and improves document organization. “Once paper documents are scanned and indexed, they can’t be deleted,” he says. “Even if they are inadvertently erased, they are still on a back-up disk. Document imaging helps provide better document security and eliminates filing space, which can then be used for more useful purposes.” Jim Thumma, vice president of sales and marketing for Optical Image Technology, Inc., notes that all the information in e-mails, faxes, and other paper documents needs to be captured and formatted for electronic storage. Document imaging enables these paper documents to be available to everyone who might need to access them. Why Document Imaging? “In every organization, there is some amount of paper being generated, and in those situations, you need to be able to digitize that paper,” says Jay Keough, business development manager for healthcare at Imaging Business Machines. “There are times that a patient shows up with a paper medical document or medical record. Scanning is the first step—and the hard part. You need to take that paper and digitize it somehow to get it into the EMR.” Many EMRs can scan only one or two pages at a time, which means that most offices have stacks of paper waiting to be scanned. The tools, such as scanning software, that come with an EMR are often limited. Most practice management systems are capable of procedures such as billing and scheduling but have limited, if any, way to bring all documents together via document imaging, notes Thumma. “It’s not all about technology as much as it’s about mental conversion from paper to an electronic document,” he says. “Document imaging is one step toward an EMR. I see it as a stepping-stone, a way to bridge the change between paper and electronic documents.” An EMR will not eliminate paper completely, although it will reduce the amount of paper that is handled daily in the organization. “Document imaging should be a component of an overall data management solution,” explains Griffith. “The EMR may be valuable from a clinical perspective, but if the EMR does not comply with the business needs of HIM, business office, and risk management, the hospital would need a more organized and proven method of complying with the workflow and retention requirements.” Systemwide Makes More Sense There is no good reason why hospitals should not consider moving to a hospitalwide imaging system, according to Griffith. One barrier, however, might be financial. Scanning is more expensive than microfilming, so it needs to be budgeted for well in advance of implementation. “There are still a really good number of hospitals and doctor’s offices that have not implemented this technology yet,” says Keough. “To buy into an organizationwide implementation may be too much for them, either technology-wise or financially. Traditionally, one department or hospital obtains a new technology, then subsequently rolls it out to other departments or locations,” explains Keough. Some reasons for not implementing systemwide document imaging are personal. Many people fear change and dread the potential for errors and failures that accompanies the introduction of new technology. “Some hospitals and IT departments see document imaging as lower-level technology, not cutting edge,” says Griffith. “As a result, they don’t move toward a solution with scanning as a component. I think that many hospital administrators are not aware of the practical, cost-effective alternatives that imaging brings as a part of the overall electronic health record initiative.” What to Look for • software that is proven in all types of hospitals, ranging from large university to community-based hospitals; • intuitive software designed around the user’s preferences; • security, auditing, and reporting are key, as are features required for specific departments (ie, electronic signature and chart deficiency modules); • a solution that grows with the organization—one that will integrate with the future requirements of various departments, workflows, and clinical systems; and • easy navigation—for most users, Internet protocol helps reduce training. Thumma also cites the need to have open, nonproprietary software with integration tools such as Web services. He mentions the need for searching capabilities within the document imaging application, which makes it easier to use, and the capability to add a user or functionality when necessary. “If a vendor can supply workflow technology to integrate into the document imaging application—which is the next logical step after you are comfortable using the application—then that enables you to standardize procedures. Sometimes, steps can become quite convoluted, so workflow technology can take care of this,” Thumma says. “Workflow is the true return on investment [ROI] on document imaging systems because it automatically processes and moves information around the organization in a standardized manner.” Thumma cites the ability to automate certain payers’—such as Blue Cross/Blue Shield (BCBS)—requirements and procedures. By automating the workflow for all BCBS claims, they managed more efficiently and moved to the right people with audit trails along the way. There is not a direct correlation between the software cost and its functionality, says Griffith. “You don’t have to pay a lot to get a lot. There are solutions available that can deliver a higher level of satisfaction and ROI while maintaining a streamlined implementation cost,” he says. The vendor’s track record should also factor into a purchasing decision—one whose experience in the healthcare industry with an organization similar in size and needs to yours is best, notes Keough. The imaging platform must be open or standardized to integrate with other applications the facility is using; otherwise, users may be unable to access documents and leverage the benefits of document imaging. “The document imaging system needs to help you take advantage of systems you already have,” says Keough. A vendor also needs to be flexible enough to add new functions as needed and provide the customer with a voice to enhance the product when required. Integrating Document Imaging
Systems Today’s common imaging platforms employ easy-to-use standard integration software, according to Keough. Document imaging technologies are well-suited to integrating with an existing hospital legacy environment. “It is unusual for a system to not integrate with document imaging software, especially for those imaging vendors who spend time and effort to focus on the hospital marketplace and integrate with common vendors,” explains Keough. Implementation Strategies “Make everyone feel involved,” says Thumma. “One organization we worked with to implement a document imaging system gave everyone a pen when they finished one level of training and a coffee mug when they finished the next level. It wasn’t much, but it was an incentive that pleased them. If people aren’t trained properly, fear will creep in and make them worry about their job performance.” Griffith acknowledges the most successful strategies involve a migration path that sets the expectations and delivers steady progress. Outsourcing can be a successful strategy because it reduces the workload at a time when employees are becoming comfortable with the new software. When they try to do too much—learn new software and adjust to workflow reengineering—it can become too stressful. “We have seen the most successful implementations occur with outsourced scanning. This enables the hospital to focus on the successful installation of the software and workflow improvements,” he says. “We encourage customers to visit hospitals with successful implementations to see firsthand how hospitals are utilizing the technology and services to make their departments more efficient, compliant, and improve employee morale. Invariably, they’ll see that creating an electronic work environment—instead of a paper environment—makes departments run more efficiently while raising employee satisfaction and productivity.” Keough agrees that a team approach is best when implementing document imaging software. The team should be composed of employees other than those in IT and the vendor. “It’s surprising how often cooperation between departments on a project like this isn’t common sense,” he says. “You have to plan the capture, scanning, and imaging, along with the workflow, and it has to be a community approach. Sometimes planning is done without the IT department being heavily involved, and then there are infrastructure issues. The existing infrastructure and standards have to be deployed with the vendor and can’t happen effectively unless the user community, vendor, and IT are all involved.” In Reserve Alpha Systems offers an application service provider (ASP) solution that hosts client data as part of a business continuity plan. In the event of a disaster, clients have access to their data through a secure ASP connection. In addition, the company provides a back-up CD to the customer, and it stores two more backups in a secure vault at Alpha Systems. Most IT departments have a disaster recovery plan that provides for data back-up and storage at an off-site facility, usually one that is in a different city or state. Today, the trend is to access backed-up data through a Web site. “Understand what your organization really needs regarding a disaster recovery plan,” says Keough. “Some need a ‘hot site’ that can be up and running within hours, and the most economical and appropriate way to plan for that is to find a company that understands your need and that is an expert on it. Disaster recovery plans can be very expensive. The requirements for disaster recovery vary widely, and you have to pick an appropriate strategy and can’t go cheap. Some plans are more ambitious, while some are underfunded.” Exit Strategy “A vendor with a proven record of migrating data is a key exit strategy,” says Griffith. “Millions of pages of data can and should be migrated to any new system. Make sure that the image file format, as well as the database, are not in a proprietary format that would require a costly conversion of the database and images to any future systems.” Success Stories “We have three sites, one 45 miles away. Now, we don’t have to wait for records to be faxed to us, and there’s no more hunting down charts. I think patients have noticed we’re more efficient. When they call, we can access their chart immediately,” explains Kelly Carlson, CCS-P, corporate compliance officer at CBHA. Since an EMR had been implemented three years prior to the introduction of the document imaging system, training was not much of an issue at CBHA. Two five-member teams prepped, indexed, and scanned the patient charts at an average of 350 to 400 per day. Today, paper has been virtually eliminated at CBHA. Lab reports are received electronically and converted to the appropriate Health Level Seven format using laboratory information software. Shorter wait times have increased patient satisfaction, while chart security has been bolstered in the new format, which supports HIPAA compliance initiatives by controlling and monitoring chart access. Areas that were once used for chart storage files are now available for patient care. MeritCare Health System in Fargo, N.D., had a similar goal of eliminating paper and converting entirely to electronic records. It utilized document imaging as an adjunct to its EMR, which has been in place for nearly 10 years. “Converting to a paperless system was a challenge because you go through the process of examining every piece of paper and barcoding everything that you want to scan. You have to understand the workflow as well,” says Caryn Hewitt, RN, BSN, MeritCare’s HIM executive partner. “I think for some people, document imaging has performed better than their expectations. The surprising part for me is how people have enjoyed the EMR solution and how easy it is to get things online.” Chart pulling at MeritCare has decreased 15% since document imaging was implemented nine months ago. — Laura Gater’s medical and business trade articles have been published in Healthcare Traveler, Radiology Today, Corrections Forum, Credit Union BUSINESS, and other national and online publications.
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