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December 11, 2006
Hybrid medical records, an intoxicating combination of paper and technology, can serve as a realistic step toward an electronic medical record. In synch with the accelerated nationwide push to transition to an all-inclusive electronic medical record (EMR), many healthcare providers are turning to hybrid systems of records management as a realistic first phase of adoption. A recent “Healthcare Provider Examination Study” conducted by Oracle revealed that 77% of healthcare providers have a plan in place to implement an EMR system with the expectation of completing the process within a five- to 10-year time frame. It’s not necessarily a new approach to maintaining patient medical records. In fact, according to many HIM professionals, the concept of the hybrid medical record has been around for many years. “In essence, we’ve always had a little bit of a hybrid record,” says Cynthia Hyde, RHIA, chief information officer (CIO) with Mobile, Ala.-based Providence Hospital. “With the advent of new technology, though, what’s happened is it has really blossomed into a number of different mediums.” Defined by the industry as a combination of maintaining records through both electronic and paper-based means, hybrid medical records, according to Hyde, are essentially information pertinent to a particular patient maintained via a number of different mediums—transcribed data, scanned images, microfilm/microfiche, paper, digital imaging and communications in medicine, and other forms of electronic media. While the majority of providers currently express confidence in their ability to complete the EMR transition, the Oracle study also reveals the existence of many stumbling blocks to effective EMR implementation. “For a significant period of time, we are going to be in this transition from a paper record to an electronic record,” says Linda Reino, CIO with Universal Health Services, emphasizing the need to focus on effective management of hybrid systems. Stumbling Blocks to EMR A key finding reported in the 2006 Oracle study designates IT issues as a major barrier to EMR implementation, with providers citing technology implementation costs and outdated infrastructures as major impediments. “For many of us, it’s a matter of cost,” Hyde concurs, recalling her experiences at the 349-bed Providence Hospital, an acute care facility. Reino agrees, saying, “There is not a huge influx of capital to make it happen. It’s a daily [battle] for the dollar. Providers are constantly up against where that dollar should go.” Another hindrance to EMR implementation noted in the Oracle study is perceived resistance by some providers and consumers to adopt electronic methods due to security concerns. “There is still a general thought process that paper is safer,” Reino notes. “Plus, what happens when the system’s down? That’s a valid concern … but I can’t tell you how many times I couldn’t find a paper chart. We forget about that.” Don’t Put the Cart
Before the Horse Amid many challenges, HIM experts still believe much value can be achieved by implementing hybrid systems and not waiting until all the puzzle pieces fit neatly for EMR. According to Reino, even a partially automated patient record can provide pockets of improved workflow and increased quality of patient care. It can also increase communication across clinician groups and drive the creation and acceptance of the usage of codified data standards. Reino also emphasizes that despite perceptions otherwise, hybrid systems allow for more secure access to patient information. “When it’s electronic, I know who looked at it,” she says, noting that HIM professionals have little control over data that has been copied and passed from one person to another. “I can actually do a better job of release of information.” Mowry suggests starting small by first identifying key areas that will give an immediate return on investment because “you want nurses and practitioners to buy into the process.” Areas of the clinical setting where the data are primarily factual in nature—such as a laboratory environment—are often the easiest places to start. According to Hyde, Providence Hospital conducted research into what types of information had been requested most often, looking at one-, three-, and five-year periods. “We did not elect to convert film or cartridge information to electronic mediums,” she says. “We started without outpatient diagnostics, emergency room, labs, and the critical components of the inpatient record.” HIM professionals agree that the emergency department (ED) holds much opportunity for an immediate return on investment via a hybrid system because the nature of the department lends itself to high-volume usage of patient data—especially in the case of records for repeat patients. “Information needs to be online as immediately as possible [for EDs],” Reino says. “It can provide one of the biggest benefits to the emergency room.” In the case of EDs, there are typically low volumes of chart data per episode and more straightforward, consistent documentation. Reino says the initial phase of converting ED data will usually result in a mix of paper and electronic information, including clinical documentation on paper, electronic orders, and online results. Inpatient records present some of the most difficult challenges to the hybrid system because much of the information is subjective, says Mowry. In the case of inpatient records, physicians and nurses are documenting observations of patients on a daily basis and much of it is handwritten. “Usually the last frontier is getting the physicians’ progress notes automated,” she says. In the case of patients who already have medical records on file, healthcare providers will have to weigh the benefits of converting all or some historical data to electronic form. Because exporting all the data from thousands of charts in a typical scenario is long and costly, Mowry suggests that such a conversion makes little sense for all patients. While the hybrid transition brings many benefits, Mowry cautions that the process can bring its own set of challenges to the medical record. Because some of a patient’s information is paper-based and some can be accessed electronically, practitioners will often become frustrated with trying to find the data. “The problem is that physicians need a holistic view,” she says. “You’re asking a clinician to separate how he or she does their work when they are used to just flipping through a chart.” In her experience, Mowry has witnessed the paper-based part of the medical record become more complex in the hybrid record phase because frustrated practitioners will request that reports be printed to avoid having to look up data via several different mediums. “It ends up that nurses are doing more paperwork, the chart is bigger than it was before, and you have only automated [one area],” she says. “There’s a lot of information within the manual record that is unnecessary,” she says. “We need to understand all the things that we’re doing for a patient that won’t make a difference [in an electronic form]. When you streamline, you should see costs reduced and care improved.” A hybrid medical record system will also mean an HIM department will have to reengineer the way it does business. “You have to redesign your department for how they are going to work in an electronic world,” Hyde says, adding that at Providence Hospital, it meant everything from the physical layout to the staff’s skill sets. “Some of the challenges we saw were the competency skills sets of people change rapidly,” Hyde notes. For example, computer skills were not a primary skill set when medical records were paper-based. When Providence began transitioning to electronic methods, Hyde says some of her staff could not catch up and ultimately had to be transitioned to other, more suitable areas of the hospital. In the case of physical layout, Hyde notes that in “simplistic terms,” the department went from a compartmental design to a more open, centralized system. Changing Face of HIM Reino concurs, adding that the HIM director needs to be aware of how investments in new technology throughout a hospital or clinical setting will affect the hybrid transition phase and the overall plan for an EMR. “Does the new system interact with the core clinical system?” she questions, adding that when ancillary departments make choices about new systems without involving HIM, it can actually slow down the process. “You’re finding more and more HIM departments coming under IT.” Reino says that departments acting as “islands” in a clinical setting are a hindrance to implementing effective hybrid record systems. Hyde suggests that resources will have to be allocated to get HIM personnel up to speed with new technology as well as train other key departments and staff throughout the clinical setting. “You have to put your people on an education path to learn new competencies,” she says. Training will also become a responsibility of HIM professionals as hybrid systems are implemented. In the case of Providence Hospital, the HIM department does not provide 24/7 coverage, making it necessary to train key nursing staff on how to access medical records during late-night and early-morning hours. “We’ve had to make sure we have the right folks educated about our processes. There’s a lot of liaison work from HIM working with nursing staff,” Hyde says, adding that the process has to be user-friendly to work. “If we don’t make it easy, we’re going to have to spend resources to staff that shift.” Hyde says staff have been very receptive to the new roles and responsibilities because it actually makes “life in the HIM department a lot easier.” Reino agrees, noting that staff had realized a huge benefit working with some electronic records, and it had streamlined customer service. “It’s all done from the desk now,” Hyde says. Technical Considerations To effectively transition from a paper-based record to a hybrid record, Reino says an electronic documentation management system will need to exist that can provide for the following: • electronic integration of existing online components; • capture and storage of imaged pages of the paper chart allowing for high-speed scanning as well as point-of-care scanning; • automatic indexing of information via patient medical record number, episode number, and chart component; and • an online chart view with delineation of chart components. From an equipment perspective, Reino emphasizes that organizations will need to make plans for standardized scanners, ample devices for physician and clinician access, and coders that can access multiple applications. She notes that it will also require a top-down approach where senior management, administration, nursing departments, physicians, and HIM professionals are voicing support of the effort. “What the industry needs to do is be totally committed to moving forward,” she says. — Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications covering everything from corporate and managerial topics to healthcare and travel.
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