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For other articles and previous issues click here. October 21, 2002 Ex-Files The truth is out there: Well-oiled
document management systems help keep alien data at bay. Electronic medical record (EMR) systems, however, are not inexpensive. This fact causes many small- to medium-sized facilities and private practices to fall behind, mired in mountains of paperwork and without the resources to alleviate the strain. The solution? According to many experts, document management can afford smaller healthcare organizations and practices the opportunity to streamline workflow processes, enhance document retrieval time, and, most importantly, improve patient care. Whether electronic or paper-based, one problem associated with healthcare documents over the years has been the lack of indexing and organization that allows a practice or facility to function efficiently and make the best use of collected data. “Many facilities have invested heavily in transferring their paper records into electronic formats, and have invested an exorbitant amount of money in electronic storage,” according to Frank Naeymi-Rad, PhD, MBA, chairman and CEO, Intelligent Medical Objects, Inc., Northbrook, Ill. “They have not been categorizing the documents within a context or category and have not looked at the medical concepts supporting their data.” What is needed, Naeymi-Rad explains, is a general classification or key word list, which would allow a facility to attach meaning to documents, thereby enhancing their potential uses in the future. “Perhaps the most important future use is in the context of the electronic medical record. In other words, with the right system architecture, document management systems can be made to serve as components in robust EMRs. Now you have the best of both worlds being combined into a powerful, well-organized healthcare tool.” EMRs have traditionally lacked such organization, according to Naeymi-Rad, because of the immense amount of data collected by healthcare personnel. The same is often true of document management systems. When a facility invests heavily in implementing an EMR system or a document management system, the initial concern, he says, is ensuring that information that used to go into a paper file will be readily available for clinicians who need to make immediate medical decisions. At the same time, administrators are also trying to meet various federal and state compliance requirements associated with patient privacy and medical information security. “Haste, driven by the desire to show fast ROI [return on investment]; and shortsightedness, driven by a lack of appreciation for the medical value of richly indexed information, have typically resulted in a straight image repository environment rather than a series of documents in context within a repository,” he adds. Naeymi-Rad describes the further complications resulting from a lack of hands-on clinician documentation in traditional environments. “We have always relied on the person scanning the records, usually clerical personnel, to add some sort of classification,” he says. “These people, though valuable employees, do not have the same level of training as a nurse or physician who is actually delivering the care.” New technology related to physician dictation, including speech recognition, improves the possibilities for document management by involving the author of the document in its classification from the outset. “If the authors—the physicians—have to validate a dictation that is sent to India or Ireland for transcription by signing off on it the next morning, they are forced to read it,” he explains. “It is possible to do more with a document in which the words are already in electronic form, rather than simply a scanned image of a paper document; but, the same technique used in dictation validation can be used to have clinical authors sign off on the image of the document, thereby allowing them to add clinical classifications to the images indices.” In any EMR system, there will exist some information that must be maintained as private, as well as information that must be made available to multiple persons throughout the practice or facility. Complex security systems, therefore, are essential components of any document management system, according to Laurie Shufeldt, business development manager, FileVision USA, LLC. “The best systems have document-level security, password and user name login, and audit trails,” Shufeldt says. “Document level security allows a document requiring limited access to be stored in the same location as a document that needs to be accessible to everyone.” Audit trails, she continues, provide information about “who, what, when, and where,” detailing every time the document has been accessed by someone. “There are many variations of these tools,” Shufeldt adds—including FileVision Version 2.2’s completely searchable audit trail—that, taken together, ensure that private information is maintained as securely as possible. Many in the EMR industry foresee a potentially positive impact from the Health Insurance Portability and Accountability Act (HIPAA), according to Dave Gillis, vice president, Freedom Imaging Systems, Ypsilanti, Mich. Gillis explains that because there are several components of HIPAA, it is difficult to determine where the primary focus is at the moment. Medical records, however, are receiving an enormous amount of attention, resulting in increased business within the document imaging industry over the past six to eight months, he notes. “Most healthcare professionals have a very good, basic idea of how they are going to adhere to HIPAA requirements,” he says. “Over the next few years, I expect we will encounter a growing number of opinions about HIPAA and solutions regarding how best to manage documents while maintaining compliance.” Benefits achieved by implementing a document management system range from improved workflow to better patient care, depending on the size and focus of the facility or practice involved. Gillis notes, for example, that Freedom Imaging offers a workflow module designed to assist laboratory personnel with processing documents. Typically, in a laboratory environment, a request for a procedure comes in paper form, which is handed to the billing department to perform data entry. “We offer them the opportunity to scan those documents electronically using software that gives them an image of the actual requisition on one side of the screen and the billing software on the other side,” Gillis says. “They can do billing directly off the screen.” This is a paradigm shift for billing personnel, who are typically used to holding the actual paper requisition in their hands, he adds. Therefore, it may take those people some time to get used to a new procedure. The benefits, however, are apparent to organizations that need to know where documents are at all times, especially during billing and accounts receivable processes. The biggest potential benefit document management systems can offer a small practice, Shufeldt explains, would be an expected increase in productivity. “In small practices, administrative staff are usually pressed for time,” she says. “A good document management system can help them streamline their workflow and save time. It could mean the difference between hiring new personnel or not.” Gillis adds that most facilities should not expect a document management system to enable full-time personnel to be eliminated. Instead, processes will be changed as employees become more efficient and their productivity is increased. “What that means is that a growing facility will probably be able to go a longer time before needing to hire another full-time employee, compared with what you might expect in a growing paper-based environment.” Naeymi-Rad explains that the primary financial benefit offered by most document management systems is improved quality of collected data, resulting in drastically reduced billing errors and reimbursement problems. “Document management allows the healthcare administrator to enhance billing processes and, at the same time, enhance the quality of storage of documents for future reference,” he notes. For example, by properly indexing and storing documents, the data they contain is more readily accessible for clinical research. In addition, documents can be enhanced to meet the needs of specific users, including nurses, physicians, and patients. Measuring return on investment for document management systems involves examining at least three areas of interest: time/productivity, consumables, and physical storage costs, according to Shufeldt. “Time and productivity relates to all of the time previously spent looking for lost or misfiled documents, making multiple copies, and filing them into multiple locations that can now be diverted to other tasks,” she explains. “Also, less time will be spent on business processes that can now be automated, including updating and sharing documents.” Consumables, she explains, consist of products that must be purchased to maintain a paper-based environment, including toner, paper, and office equipment maintenance. These expenses are often greatly reduced in electronic environments, as are the costs of office space, storage facilities, and filing cabinets. Gillis adds that eliminating microfilm costs can also save a facility several thousand dollars each month. “There is also the invisible, soft costs of the time it takes employees to get up from their desks and walk to a filing cabinet to get a document, then walk back to their desk and answer questions from clients or coworkers,” he adds. In some cases, he continues, documents are stored off-site, requiring days instead of minutes to retrieve. “It can be quite difficult,” he admits, “to explain to chief executive and financial officers that the return on investment may come in the form of saving the time it takes for an employee to alphabetize files or walk to a file cabinet.” Healthcare professionals, whether clinicians or executives, do respond to potential improvements in patient care, which is, after all, the primary goal of the industry. “In many cases, if a physician needs to confirm tests on a laboratory requisition, and it is two days away, new tests, if ordered, may be repeated unnecessarily,” Gillis says. “One convenience to the patient is in the likelihood he or she will not need to have blood drawn again because the lab report is at hand.” Having patient information accessible and quickly retrievable logically results in faster, more convenient, and potentially cost-efficient care. Challenges inherent to document management systems are primarily related to employee training. “Change is always hard,” Shufeldt admits. To help enhance their system’s ease of use, FileVision’s File Manager allows clients to actually duplicate their current filing system with graphical file cabinets that appear on the user’s screen. “This system requires very little training, so new staff can learn to use it without costly and time-consuming training,” she explains. Bar code placement is another difficulty that administrators and document management system developers have been required to address, according to Gillis, who says that in most laboratories, harried technologists place bar codes almost anywhere on a requisition form, so long as they are not covering important information. Bar codes slanting to the right or left make scanning more difficult, so standardized placement is critical, Gillis notes. “It is more efficient if they are placed in a consistent location, as horizontally as possible. We have improved our software to rotate the document to try to align the bar code to the reader, which has taken us from a 5% misread rate to a 1% or 2% misread rate, saving a lot of time.” It is important, Gillis says, to continually train and update staff to identify any potential problems and reeducate personnel as necessary so they understand the scanning system and how it operates. Other challenges to effective document management include document quality, which can be affected by incomplete laboratory requisitions, printer ribbons in need of changing, and duplicates of duplicates. “If the quality of the document is not great, it is important to educate customers and advise them to change their printer ribbons,” Gillis says. “There is software out there developed to enhance poor-quality documents, but it adds to the cost of the system.” Naeymi-Rad predicts that, in the future
of healthcare document management, clinicians will be able to create
interfaces with electronic clinical notes that will enable them
to learn more about their patient population and reference historical
information. “In the past, we have used document management
as a storage system, mainly to preserve paper documents,” he
says. “By storing the image based on the key words used by
the clinician, we add a layer of intelligence that allows document
management to merge with the electronic medical record and create
improved knowledge about how a specific patient is cared for or
how an error occurred, all in the context of time and problem. This
helps providers to offer better care to their patients, which is
why we work in healthcare IT [information technology] in the first
place!” • Ease of use. “In order to be most effective, any document management system should be easy to learn and use,” says Laurie Shufeldt, business development manager, FileVision USA, LLC. “If the employees don’t understand a system, it is doomed to fail.” • Security. Practices need security features, including document-level security, password and user name login, and audit trails, Shufeldt explains, in order to attain and maintain compliance with federal and state requirements. • Versatility. “It is important that the system does not interfere with your tried-and-true methods, and instead actually enhances them,” Shufeldt notes. “A physician’s practice or healthcare facility is a business with multiple departments that should all benefit from the selected system.” The main focus may be patient records, for example, but the system should also address accounting and human resources concerns. • Vendor experience. “I suggest contacting existing customers to find out more about the company’s history,” says Dave Gillis, vice president, Freedom Imaging Systems. Working with a vendor who understands the needs and concerns of your particular specialty or field can make all the difference in a long-term relationship. • Retrieval time. “There is a lot of software out there that can perform scanning and give you an image online or digitally,” Gillis explains. “The more important issue is how quickly you can actually get to that image.” Potential buyers should ask a vendor
how growth in their business will affect retrieval. “If you
go from 100,000 to 1 million images, how quickly will you be able
to retrieve them?” he poses. “There are many reasons why
a document management system can fail in a particular organization,
but often it is because the system cannot handle an increased volume.” |
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