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September 26, 2011

Pulling Double Duty
By Selena Chavis
For The Record
Vol. 23 No. 17 P. 24

Industry professionals offer advice on how to manage dual paper/electronic systems.

Hybrid medical record environments have been around for as long as many HIM professionals can remember, and most believe they are here to stay for the foreseeable future. In fact, the push toward EMR adoption and other advanced HIT environments has only exacerbated the situation as organizations strive to meet meaningful use (MU) deadlines.

“MU has been a great boom to getting organizations to become electronic … but that doesn’t mean the paper has gone away,” says Deborah Kohn, MPH, RHIA, CPHIMS, FACHE, principal with Dak Systems Consulting. “More people are now in hybrid environments than ever before. MU means more hybrid records.”

Defined by the industry as a combination of maintaining records through both electronic and paper-based means, hybrid medical records, notes Kohn, can best be described as information pertinent to a particular patient maintained via different mediums: transcribed data, scanned images, paper, DICOM (Digital Imaging and Communications in Medicine), and other forms of electronic media.

Many types of hybrid environments can be found in hospitals. Typical formats include a combination of an EMR and paper or an EMR alongside some type of imaging.

Melissa King, manager of information management solutions with Standard Register Healthcare, points out that nowadays there is less paper within the always evolving hybrid environment as healthcare organizations attempt to move paper into an electronic environment. One of the greatest challenges of managing a hybrid system is not having the correct documentation to “marry the information into a patient record” to achieve a complete picture of care, she notes.

It’s certainly a challenge at two hospitals within the Illinois-based Provena Health system—356-bed Provena Mercy Medical Center and Provena Saint Joseph Hospital—where the legal department regards the paper-based version as the legal record.

“They are saying it’s the paper-based record because so many documents are not integrated into the EMR yet,” says Sandra Joe, MJ, RHIA, Provena’s regional HIM director, as well as its compliance and privacy officer, adding that the hospitals still print every patient file. “Is it more costly? Yes, because we are still storing that [paper] record.”

Stumbling Blocks to an Integrated Record
Many HIM professionals agree that the focus on effective management of hybrid systems is an outgrowth of the difficulties healthcare providers face when trying to fully implement an EMR. “Unfortunately, we have a lot of niche systems like everyone across the country,” Joe notes. “Some of them don’t interface with our EMR.”

Joe expects the situation to remain at a standstill until all systems can be tweaked to integrate into the EMR. Currently, the Provena hospitals are working on deploying scanning systems. “When you have a scanning solution interfaced with the EHR, then we will be able to get all the information into the electronic system,” Joe says.

The hospitals are in the process of reviewing various vendor document management and scanning solutions. Joe notes that it has been challenging to find technology that will make electronic capture a reality. “Many vendors say that their products will interface, but that’s not always the case,” she explains.

Until then, the hospitals will continue to print out all files postdischarge because patient information gaps exist in the electronic version.           

Joe says there will always be some documents that won’t interface directly, making it imperative to deploy scanning systems that integrate into an EMR going forward. These documents could encompass state forms or information provided from outside providers. “You will have to scan those in to become part of the overall medical record,” she says.

Kohn points out that many hospitals can become overwhelmed when considering all that needs to be done to pull the full patient record off the paper chart and put it into an EMR. To get started, she suggests prioritizing and focusing on key areas.

“It’s hard to run dual systems with the same amount of people and the same amount of dollars,” she says. “It’s also hard to find the time, money, and resources to convert older paper systems. Look at the most critical areas that need to be covered. You have to prioritize your various features and functions and databases.”

Paper-based processes require various procedures and steps to ensure an event occurs, Kohn further explains, adding that in a digital environment, the processes have to be reworked and reinvented.

“This process requires a good team of thought developers,” she explains, pointing to the current conundrum most healthcare facilities find themselves in: no resources to allocate to the role of a systems engineer. “You hope that you have someone who can understand the changing of all those analog [paper] processes.”

Typical priorities currently revolve around MU requirements such as computerized physician order entry and e-prescribing. “MU is directing this. Quality reporting will be a priority,” Kohn says.

When considering the many formats in which information is stored, King notes that hybrid medical record environments have to be well managed to ensure documentation does not get misplaced. “Misplaced documentation can lead to legal risks,” she says.

Also, when systems are not in place that allow patient information to be “married up” into the electronic patient record easily, a backlog in chart completion can create a chain of events adding difficulty to revenue cycles. “When manual indexing has to come into play, it slows down chart completion,” King points out. “It slows down reimbursement.”          

Technology’s Role
Bar coding has become a key component to ensuring that paper documents can be stored easily in the EMR and that hybrid medical records environments can be efficiently and effectively managed, according to numerous HIM professionals. In fact, HIMSS advocates the comprehensive use of standards-based bar-coding technology in the healthcare environment, noting a number of areas where it works best, including the following:

• patient registration and admission processes;

• patient safety, clinical care delivery, and patient tracking;

• product/supply logistics and material management coordination; and

• patient accounting and billing.

A bar code is a representation of data that can be read by an electronic device. The use of this technology has proven successful in creating efficiencies and improving productivity and accuracy in various industries. In a nutshell, the technology provides a fast, accurate method for entering data, making it effective for managing hybrid medical environments.

According to HIMSS, bar coding should be part of a greater electronic document management system (EDMS) strategy that allows migration to a digital format from existing analog and manual output and processes. HIMSS states the overriding goal of this system is to manage paper efficiently, not necessarily eliminate it.

“HIM departments have reached a point where automated solutions are becoming a necessity to overcoming the difficulties of managing so much paper,” King says.

To be effective long term, the AHIMA suggests an EDMS should be able to perform the following functions:

• Automatically fax analog or digital documents in the event only a fax machine is at the receiving end. Similarly, these systems must have the ability to automatically capture and index faxed-in documents.

• Automatically consolidate the storage, access, management, and distribution of digital source documents (EMR technology).

• Electronically assign, route, and activate an organization’s business operations and decision processes through system-controlled rules (workflow technology).

• Electronically assemble a group of documents, such as medical administration records, control the versions, and secure the documents (document management technology).

• Electronically validate the authenticity of any individual transmitting information and ensure the security of that information (digital signature management technology).

• Electronically create, deliver, and customize document content across the enterprise (document content management technology).

• Electronically file by type, legal use, and date to obey important file retention/destruction requirements. This avoids any physical handling and permits quick implementation of HIPAA-based file retention policies and procedures (records management technology).

The Impact on IT
According to Kohn, the relationship between IT and HIM is paramount to success as the hybrid medical record environment continues to evolve, especially as IT professionals try to build systems and processes that bring patient information into the EMR.

“HIM understands the processes that go behind capturing patient information to accurately code and meet regulatory requirements,” she explains, adding that the issues inherent in working through hybrid medical record environments affect both departments equally, just in different ways. “IT has no clue about the processes. It’s a team effort. HIM can be so valuable to IT folks in working out the processes.”      

The Crucial Role of Policy
Swimming in a sea of challenges, HIM and IT professionals realize that hybrid record environments will have to exist for some time to come. There is simply no way to wait until all the puzzle pieces fit neatly into a fully integrated EMR.

In that light, experts agree that one of the most important steps that can be taken to ensure hybrid environments operate effectively and efficiently is to implement a strong core of policies and procedures.

“Often policies will take a backseat,” Kohn says, adding that at the very least, hospitals should implement policies and procedures for handling documents on an internal level as well as for those received from external sources.

King suggests that before venturing into a hybrid medical record situation, hospitals and providers get organized with bar-coded systems. That way, policies and procedures can be built around the system to ensure HIM doesn’t have to accept outdated documents or forms that don’t line up with the technology.

“This process can ensure that the transition to an EHR will be a lot more successful,” she points out, adding that rules about what HIM can accept need to be fine-tuned to ensure only standardized documents are entered into the system.

“You have to make sure you are not getting old versions,” King explains. “If a document is used in a hybrid environment, ensure it’s always the latest version and it’s bar-coded. HIM should hold departments accountable and not take anything less.”

Policies to cover downtime due to network issues or disaster recovery should also be considered, King adds. “I talk to [chief information officers] all over the U.S. If [computerized physician order entry] goes down, they are reverting back to paper,” she explains, adding that in such situations there should be rules for capturing patient information, bar coding it, and getting it back into the electronic system.

Joe points out that policies concerning how release of information is handled are an important component to ensuring that healthcare organizations are correctly following protocol for releasing a legal medical record. Plus, when a complete record is requested, the process of compiling that data becomes complicated, time consuming, and costly.

One area King sees as particularly challenging moving forward is managing informed consent in the legal medical record. She notes there are EMR modules for numerous functions but few address informed consent. “This is a process that has to be followed,” she says.

Policies and procedures regarding how physicians approach their transcription and documentation also have to be tweaked and fine-tuned to fit into the hybrid process of moving paper documentation into the EMR, Joe notes.

She expects that the evolution of the hybrid medical environment to a more electronic landscape will create efficiencies and ultimately equate to less face-to-face interaction between HIM and the physician community. “When you scan, physicians won’t have to come to the medical records department anymore. The information can be accessed via hospital computers or even from home if they need to,” she says. “We won’t be communicating as closely with physicians.”

— 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.