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October 11, 2010

The Value of Enterprise Content Management
By Sandra Nunn, MA, RHIA, CHP
For The Record
Vol. 22 No. 18 P. 20

We’re not talking about how Kirk and Spock stored data on their galaxy-hopping vessel. Rather, the focus is on technology that can support clinicians and HIM staff and add punch to any EHR system.

At the Association for Information and Image Management conference in April, the IT audience was eager to learn how enterprise content management (ECM) technologies could be better sold to a healthcare market whose IT financial resources are largely committed to EHR development and meeting meaningful use requirements. Ironically, ECM vendors played a historic role in the foundation of electronic record keeping.

ECM functionality was first engaged to scan paper documents and index them in folders or under tabs for electronic perusal. Because the first “ electronic health records”  were simply scanned copies of paper records, document management vendors saw business soar as healthcare customers, along with other industries, rushed to get rid of paper. However, these imaged records were not interactive, could not be searched in depth, and could not be used as data repositories from which information could be gleaned to recognize patterns or trends that might improve treatment.

In addition, document management vendors have recognized that the traditional functions they supported in healthcare (ie, scanning old medical records, performing release-of-information processes, supporting back-office functionality such as billing) will gradually be phased out. Nevertheless, ECM vendors often still view the potential of engaging healthcare customers in terms of work they have historically performed.

There is no doubt that, in the short term, scanning projects can cut the rising cost of maintaining paper records and make paper files more accessible. But savvy ECM developers recognize that what is currently in hard copy form for scanning will soon be digital with no scanning required. The amount of hard-copy medical record content is shrinking rapidly as IT figures out how to digitize signed consents and electronically capture all care documentation no matter where it is generated.

How can ECM functionality successfully engage healthcare customers? With financial and regulatory pressure at an all-time high, healthcare customers, particularly clinicians, are looking for content management’s ability to deliver safe patient care while controlling the out-of-control costs so often bleated about in the media. The information currently scanned into EHR systems consists of handwritten notes, signed consents, drawings, and other types of images. Also arriving into the EHR as images are radiology exams, cardiovascular videos, and other unstructured information.

Some healthcare organizations are extending the basic scanning functionality of their document management systems to include the capture of the nondigitized paper associated with EHRs but not actually part of the EHR. The enterprise content system architect at Seattle’s Swedish Hospital directed an initiative in which the auxiliary content needed to support electronic records, such as advance directives, health insurance cards, and clinical content received from other hospitals, was captured into an ECM system tightly aligned with the EHR.

Other HIM leaders, in association with their clinical colleagues, are using the forms development and management functions of ECM software to create clinical forms capable of migrating into EHR systems. The enormous volume of forms that must be created to build an EHR find an ideal forum in an ECM system in which workflow functionality allows for forms to be created collaboratively among clinicians and then electronically approved for publication into the EHR. Clinical order sets can be developed in this fashion among various members of medical specialties in line with the latest approved best practices in medicine.

Another advantage of an ECM system from a legal and compliance perspective is the functionality that will permit the metadata-tagged archiving of outdated order sets and other types of clinical forms into a long-term content repository. Attorneys attempting to defend their organizations will be able to search the ECM archive and establish the standard of care applicable to a lawsuit’s time frame through the order sets and forms used to carry out care at that particular time.

A more recent enhancement to forms development through ECM systems is the ability to capture and index blocks of text that can be “ glued”  onto forms to create new documents or pieces of content. This functionality allows clinical managers, including HIM professionals, to have templates and select blocks of text to create new forms. For example, a blank job description form for a clinical coder can be filled in with the pertinent blocks of text and posted within a day. This forces a measure of standardization in language describing similar job functions. Contracts or business associate agreements can be created simply by attaching appropriate text blocks to the page, eliminating the cost of customizing every contract and allowing for standardized language. These text blocks can be titled, indexed, and archived for future reference just like other types of documents.

With the arrival of doctrines such as Six Sigma and LEAN Toyota that emphasize the reexamination of existing processes and the revision of such processes to improve patient care and reduce costs, ECM offers some distinct support. Team documentation of the existing “ way it works”  can be captured in an ECM system. When the process is altered to enhance performance, the new process can also be documented and captured in an ECM system along with any new forms created to support the new clinical process. When clinicians are inclined to revisit the process, the previous documented information (narrative and graphics) will be at hand for revision. Not having to start from scratch is enormously helpful to cash-strapped healthcare entities.

One particular type of file is recognized as problematic by clinicians and other healthcare workers: e-mail. Because it is such a huge component of everyday life in healthcare, e-mail is often taken for granted and not thought about in legal terms. However, it is increasingly requested by subpoena or court order.

The purported ability of ECM systems to build and manage large e-mail archives will indirectly support EHR development. Ahead of most healthcare organizations is the need to think constructively about e-mail and its management. There is a distinct need to distinguish e-mail provided in a patient-provider context, which would make it part of the EHR, vs. e-mail that is deemed part of business content. Many ECM vendors now offer e-mail management software tailored to help healthcare organizations control costs through its handling of enormous record volumes, allowing for deduplication of redundant e-mail and automating the retention and management of e-mail designated as records.

Collaboration software, a component of a complete ECM strategy, is enormously helpful to clinicians, HIM professionals, and administrative staff engaged in the demanding long-term projects required to bring an EHR to life. For example, SharePoint sites can be used by nurses spread across geographical sites to collaborate on nursing documentation forms development, best treatment practices documentation, or writing training materials for clinicians entering the introductory phases of EHR deployment. ECM’s ability to capture and index the EHR content developed on SharePoint sites allows organizations to avoid reinventing the wheel. For example, clinicians can repurpose content developed by other clinicians and tweak it to suit other clinical disciplines. Those healthcare entities participating in Six Sigma/LEAN Toyota efforts to reengineer clinical processes in parallel to rolling out an EHR get double value from ECM functionality. In fact, they’ll be able to do the following:

• capture original clinical and business (HIM) processes, including videos created of patient processes, prior to EHR implementation;

• capture redesigned clinical and business processes built to accommodate the use of EHRs;

• index process maps and videos for sharing with other clinical teams to gain enterprise value; and

• automate retention on process files to control long-term storage costs.

When organizations heavily invest in ECM technology, there are more tools to support EHR development and management. In a full-blown ECM system, the software can organize, index, and control thousands of diverse, EHR-related information objects. These items can be clinical policies and procedures, protocols and guidelines created for patient care, or clinical competencies such as the nursing versions found in any nursing document library.

In full ECM deployments, clinicians can “ subscribe”  to the content pertinent to their specialty and receive automatic updates whenever there are content changes that apply to their line of work. Through collaboration sites, physicians and nurses can share new clinical literature or post updates to clinical treatment practices that change the standard of care.

Less directly related to immediate patient care, the records management module of an ECM system can help HIM professionals and clinicians engaged in the process of decommissioning legacy clinical systems. ECM can track the documentation required when EHR software systems are replaced with new technology, keep a ledger of where electronic records have been moved during the shut-off of the older clinical system, and archive the decommissioning documentation for use by future HIM directors.

One of the best cost-control aspects of ECM technology is its ability to automate the recording of all documents and information objects archived in the ECM repository. In a paper world, retention must be managed on a record-by-record basis, frequently based on the last date of activity in the EHR system. ECM systems allow electronic records to automatically expire on a predefined date or to be deleted from the server when no activity in the file has taken place (ie, when a patient has not had any activity in the healthcare organization for 10 years or more). This automation saves enormous amounts of human intervention and cuts the need for staff to manage the retention function.

Healthcare organizations with greater IT resources can use the records management function present in full ECM suites to organize collaboration farms (groups of sites) such as those created with SharePoint. Tracking and indexing the migration of those clinically pertinent files deemed records from a SharePoint farm to a records repository permits the shutdown of abandoned or terminated collaboration sites while retaining the team-based knowledge generated on those sites.

Finally, a well-implemented ECM system helps today’s healthcare systems meet American Recovery and Reinvestment Act requirements by tracking accounting of disclosures of protected health information from an EHR. The same system can track any patient information breaches, including how such breaches are mitigated in accordance with legal requirements. Malpractice cases and other types of litigation can also be tracked along with supporting documents.

Beyond direct support for clinicians, ECM systems can help HIM organize, maintain, and control the files that must be kept to manage multiple audits, including those conducted by recovery audit contractors and Medicaid integrity contractors. In fact, audits of any kind can be better managed with an ECM system in place.

In general, investments in ECM will be applied to more and more clinical applications as EHRs become more complete and widespread.

— Sandra Nunn, MA, RHIA, CHP, is a consultant with Melinunn Consulting in Albuquerque, N.M., and a contributing editor at For The Record.