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October 2, 2006
HIM directors discuss their ideas on how to best implement a solution that will meet an organization’s long-term goals. Document imaging has come a long way since its debut in the mid-1980s—as has its early reputation as an expensive, labor-intensive technology of questionable reliability. Today’s document imaging systems take full advantage of advances in hardware and software technologies, not to mention the groundbreaking work of early HIM adopters in key areas such as workflow redesign and policy and procedure development. Increasingly, healthcare organizations are capitalizing on these advances, whether they maintain a hybrid patient record and use document imaging to convert the remaining paper-based portions of their patient records to an electronic format or turn to the technology as a first step to a future electronic record. As the technology has grown in functionality, ease of use, and reliability, so has the number of products available on the market. With so many products from which to choose, the selection process alone can seem daunting. Selecting the right product, however, and designing a viable implementation plan can make the difference between going live with a system that facilitates an organization’s electronic health information goals well into the future and going live with a system that will need replacing within a few short years, thus hampering future progress. This was the case for Chattanooga, Tenn.-based Erlanger Health System. This academic teaching hospital with more than 800 beds had been close to implementing a document imaging system for clinical documentation when HIM director and privacy officer Rita Bowen, MA, RHIA, CHPS, insisted that the process be stopped. “The project had become a runaway train,” says Bowen. “I felt strong in my convictions that we were on the wrong track. I knew that we would need to start over with a new system in two years because the system we were implementing could not meet workflow enhancements and other goals the organization wanted to achieve.” How could Erlanger have been so close, yet so far, with its selection and implementation of this system? In Bowen’s experience, the situation in which Erlanger found itself is not uncommon. The health system’s patient accounting department had been using a document imaging system successfully and decided it could extend use of the application to encompass clinical documentation. Unfortunately, Erlanger’s HIM department was not closely involved with the decision or the implementation planning. Workflow issues became the key problem and were what ultimately led Bowen to risk her career at Erlanger by resolutely pursuing a halt to the implementation. In the end, she won her case, which included not simply putting a stop to the current implementation but also beginning a new selection and implementation process on a different, more success-oriented track. First Things First: The HIM
Role “As an enterprise, we had pockets of the medical record in various parts of the organization that reflected different policies for documentation,” explains Bowen. “[This project allowed us to] set up new policies for consistent documentation.” It also meant developing a more comprehensive strategic information management plan with greater involvement from both HIM and Technical Management, Erlanger’s information services/technology department. HIM brings other competencies and expertise to the selection and implementation table. For example, it is uniquely positioned to understand the information needs of the clinical and financial/other administrative sides of the healthcare enterprise and thus to know how those needs must be met by a document imaging system. Its day-to-day working knowledge of HIPAA and other accreditation and regulatory rules in important areas such as security, privacy, and confidentiality of patient information puts HIM in an ideal position to advise on how these issues will be impacted by a document imaging system. And because of its responsibility for coding, HIM can help ensure that coding considerations are factored into selection and implementation planning and execution, thereby helping to optimize the bill drop cycle for reimbursement purposes. The Project Team and Plan: Don’t
Start Without Them Whitefish, Mont.-based North Valley Hospital wanted a single document imaging system that would accommodate clinical documentation, the organization’s business office, and human resources, so its project team brought together representatives from those areas. And because it opted for a phased implementation, staff involvement varied “depending on the phase we were in,” explains Traci Waugh, North Valley’s director of HIM and compliance. “For example, when we implemented the system in the ER, the ER manager, ER nurses, and physicians were more involved.” In Erlanger’s case, two Six Sigma teams were included—one that addressed documentation needs and flow and another that addressed charge master needs. These additional teams assisted the overall team, co-led by Bowen and her counterpart in Technical Management, to focus on a workflow redesign that would help ensure correct reimbursement. A multistakeholder approach also helped Erlanger flush out user expectations from an online medical record, which enabled Bowen and the project team to factor the needs behind those expectations into the selection criteria and implementation plan. For example, the staff responsible for the cancer registry expected electronic access to patient records to complete their required submissions, so it needed information to flow to and from its area online. A project of this magnitude demands a well-defined plan with assigned deliverables and deadlines. “Project management is essential,” stresses Bowen, who, along with the project’s coleader, relied on the project management tools available in Microsoft’s Project 2000 software. Bowen recommends sharing the project’s timeline with stakeholders to facilitate both realism and buy-in. She believes this was especially important for planning Erlanger’s form redesign phase, which required properly bar coding the new forms. Bowen also advises defining the project’s organizational structure, including the roles and responsibilities of those involved, then linking these aspects to the timeline. The RFP: Clarify Needs and Define
System Criteria Since Erlanger identified workflow enhancements as one of its high-priority goals for implementing a document imaging system, Bowen, who took a full two weeks to write the organization’s RFP, focused many of the criteria on user expectations for workflow enhancements, which included needed workflow tools such as alerts signaling missing documentation. She puts this under the general heading of “having the end state in mind” from the outset. For Bowen, the end state includes anticipating future needs. She believes the best way of accomplishing this is to stay in the loop—that is, staying current with developments in HIM, from industry trends to law and regulatory issues through professional journals and magazines and active participation in professional associations, such as the AHIMA. For Spartanburg Regional Healthcare System in South Carolina, one of its overarching needs for a document imaging system was integration within its enterprise information system which spans three hospitals. “Integration was our biggest concern and now it’s our biggest success,” says Lynne Henderson, MHA, RHIA, Spartanburg Regional’s HIM director. Like Bowen, Henderson recommends honing in on your organization’s identified needs rather than on more general product attributes, such as a system’s ranking as best of breed. “Don’t look at best of breed,” advises Henderson. “If the system doesn’t integrate, it doesn’t do us a lot of good that it’s best of breed.” Site Visits: Use Them to Your
Best Advantage Bowen’s team at Erlanger capitalized on site visits to get the kinds of hands-on, additional information the team needed to make a well-informed selection. The team operated from the premise that the site visit was their time and therefore it needed to be responsible for structuring the visit according to their information needs. Key aspects of that structure included a standard agenda, scripted scenario questions and cases, a sample workflow, and a four-member site visit group that remained the same for each visit. “[Evaluation] consistency was the main thing,” explains Bowen. “It was important that we had the same people asking the same questions the same way at each site.” The site visit group went so far as to record their interviews so specific details could be reviewed. During a site visit, the Erlanger group was especially interested in getting an overview of how the imaging product worked across the site’s enterprise, hence the scripted scenario questions and cases. The group also wanted to see how the site’s physicians were affected by the implementation. Next to workflow enhancements, ease of use remained a significant consideration, particularly for the medical staff. In addition to the scripted scenario questions and cases, the sample workflow gave them another angle from which to evaluate the system’s ease of use. “We asked the sites to run our sample workflow to see how many steps were involved on that particular system,” says Bowen. Implementation: Key Elements
That Facilitate Success Waugh concurs. “Forms management is imperative,” she emphasizes. “Start working on your forms early in the process—even if you’re just thinking about going the document imaging route.” Waugh also recommends looking critically at the layout of the form and how to incorporate essential elements for scanning, such as bar coding. Consider—or reconsider—design elements that can add to scanning time, such as the color or shading. When forms are “clean,” staff can prep and scan much faster and more efficiently. A strong staffing plan also facilitates a successful implementation. The redesigned workflows that are an integral part of a document imaging implementation offer many healthcare organizations the opportunity to reevaluate how they are staffed and the deployment of individual staff members. “We restructured our staff and redefined the job descriptions for staff positions in an electronic department as opposed to a paper department,” says Henderson. Henderson started by making all clerical positions in HIM one job grade. She next considered who was on her staff and what needed to be done, then went about reassigning individuals to jobs for which they were better suited. “For example, I had an analysis clerk who became a customer service representative because she was so good at communicating with the doctors,” explains Henderson. “It didn’t make sense to keep her as an analyst when she was so good with people.” The result has been high employee satisfaction, retention, and productivity. “We don’t hire temps,” says Henderson, “and we have no problems with backlogs.” Bowen is taking a similar tack at Erlanger. “We based our staffing plan on our enhanced workflows,” she says. “Now instead of chasing paper, we manage information.” Bowen’s staff has realized additional benefits, too, such as continuing education, a win-win for individual staff members and the organization. “We worked with the local junior college and encouraged many of our staff to go back to school—and they did,” says Bowen. “We really pushed them to pursue an RHIT degree,” she says, adding with obvious pride, “and this year, more than 20% of the graduating class were staff from my department.” Better trained staff can only help the organization’s efforts to manage information and make best use of it for patient care and overall operations. While most people wouldn’t overlook testing, the issue for successful implementations seems to lie in degree. “Test, test, test, test,” says Henderson, who ran Spartanburg Regional through two mock go-lives in addition to scenario testing. The first mock go-live ran for one week, the second for two weeks and covered every possible diagnosis. Henderson found that the level of testing she ran helped her to not only assess the system and new processes but also to verify her staffing plan. She had additional objectives in mind regarding staff. “I wanted to give staff time to get used to real-time scenarios and the software outside of the training environment,” she explains. Ultimately, Henderson wanted to make a thorough examination of the document system from entry through delinquencies and bill drop and to iron out identified issues in the system, processes, and staffing prior to go-live. Go-live timing is another important element to plan carefully. “If you have control over when you can implement,” Waugh says, “consider such things as staff vacations and known periods of peak patient volume.” Waugh’s “if” recognizes the reality of constraining factors that some healthcare organizations may face and the need to build accommodations for those factors into the implementation plan. This was the case for North Valley, which implemented document imaging this past June. “We’re in a resort community and summer is one of our busiest times of the year, but we had to push implementation quickly because of our move,” notes Waugh, referring to the new building the hospital is constructing and into which it will move next February. “The new building has less storage space for HIM records,” she continues. “We needed a solution besides off-site storage.” Part of Waugh’s solution to her implementation challenge was to go with a phased implementation, starting with records for the emergency department, same-day surgery, and observation stays. Inpatient records and the rest of outpatient records will follow this fall. Finally, it may be helpful to consider go-live a milestone rather than an end. “It’s important to realize that selecting and implementing a document imaging system is not the end,” says Bowen, referring to the ultimate goal of operating in a fully electronic environment in which all clinical documentation is entered into the system at the point of care. “HIM must stay involved in converting to an electronic documentation capture process,” she advises. “This might take four or five more years, but it’s important that the right documentation is identified for the right needs in the record.” — Aggie Stewart is a freelance writer and
an editor, specializing in HIM and HIT. She also serves as consulting
editor of Health Information Management Manual, 2nd edition.
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