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November 8, 2010

Forms Automation — HIM and Beyond
By Alice Shepherd
For The Record
Vol. 22 No. 20 P. 14

By addressing the distribution of forms—both clinical and nonclinical—throughout the hospital, healthcare organizations can create space and save money.

Hospitals are paper-intensive organizations. Even those that have implemented EHR systems find themselves using a great deal of paper, much of it in the form of nonclinical and quasiclinical work process forms. According to Scott Wallace, vice president of strategic development and channels for Standard Register Healthcare, the number of forms in hospital departments varies greatly based on the specialty, services provided, region of the country, payer mix, languages supported, and population. Some departments have as few as 20 forms while others have hundreds.

Wallace cites a HIMSS Analytics report showing that although 47% of U.S. hospitals currently have electronic forms management software or at least a service contract, many are underutilizing their document automation systems by automating fewer than 50 forms.

Save Big With Forms on Demand
Darice Grzybowski, MA, RHIA, FAHIMA, president of HIMentors, LLC, which offers HIM and forms management consulting, believes there are a number of forms whose automation could make HIM and other departments more efficient, including duplicate medical record number identification tracking forms, forms related to the destruction or purging of records, forms that note when a record goes to committee, signature processing approval forms, billing-related processing forms, forms for the interdepartmental routing of approvals or requests for information, human resources forms, inventory forms, and release-of-information tracking documents.

“A great deal of typing can be avoided by prepopulating these forms with information from an electronic document management system, the EMR, or an archival system,” says Grzybowski.

There are two basic types of forms automation. The simpler is management software that catalogs forms. It is variously referred to as “forms on demand,” “just-in-time forms management,” or “electronic forms inventory.”

“Users can log in to the system, choose a form from a menu, and print it as needed for hard-copy use,” explains Kelly McLendon, RHIA, president of Health Information Xperts, LLC, which helps guide hospitals through electronic document management projects. “An example of an HIM form that is often automated in this fashion is the coding query, a quasiclinical form which is considered part of the legal medical record in some hospitals but not in others. With simple forms management software, coders can print the query form at the push of a button, fill it out, and send it to the physician in hard copy.”

“Since the majority of hospitals still print forms, make copies, and give them to departments, just-in-time forms management makes it easy to custom print and modify forms,” says Grzybowski. “It makes for less waste, and the forms can be printed with the patient identifier on them, which improves safety by avoiding mix-ups.”

Hospitals typically implement such a forms management program for the entire enterprise and for both clinical and nonclinical forms. Rollout usually begins with the admissions department’s patient registration and consent forms and proceeds to other medical record forms that are not slated to be replaced with completely electronic versions.

“Hospitals which purchase forms-management software can save hundreds of thousands to $1 million a year on preprinted forms and labels they would otherwise purchase from a vendor,” says McLendon. “Forms-on-demand technology also reduces the need for storage space because forms can be printed in small quantities and distributed to departments rather than maintaining large vendor shipments in a storage facility.”

Grzybowski also appreciates how the technology creates open space in a facility. “Saved space is also saved dollars for facilities,” she says. “Large inventories of stored forms and the need to dispose of outdated forms are avoided with an electronic forms-management process.”

White Memorial Medical Center in Los Angeles recently rebuilt a large portion of its facility and did not invest in a great deal of shelving because it expected to be further along with its EMR implementation. “We realized that we only had storage space for a limited number of documents,” says Vice President Mara Bryant. “Our DocuShare enterprise content management [ECM] software from Xerox allows us to manage documents and forms electronically, reducing storage requirements and bridging the gap between the current paper world and a totally electronic future. The ECM system gives us a secure place to keep our business documents without clogging up the clinical records system.”

The hospital estimates annual savings of more than $200,000, including substantial productivity gains.

McLendon points out that the benefits from forms management software multiply when it is linked to a hospital’s admissions, discharge, and transfer (ADT) system to automatically print patient names or bar codes on the forms. “There is no longer any need to affix labels, which makes scanning more efficient. And once the forms are scanned, the hospital’s document management system can easily classify them according to document and patient, which minimizes errors and increases safety,” he says.

For example, Health First in Brevard County, Fla., has seamlessly integrated its FormFast forms management technology with its ADT system. Judi Spillers, senior software engineer, explains: “The ADT system sends the information the registrar has entered to the FormFast server just as if it were a print job going to a printer, so there is no need for an interface between the two programs. The … server captures and reads the information and prints the necessary forms (eg, inpatient packet) for the patient to sign. The program also looks for language preference and prints the forms in Spanish, if necessary. The registrar immediately scans all completed and signed forms into the ADT system to make them available to HIM and other departments. An added benefit of forms management software is that forms can be modified quickly and efficiently when an external party such as Medicare or an insurance company asks for changes. It would take much longer to modify forms via a print vendor.”

The hospital plans to go completely paperless in the future, including e-signature tablets for patients.

Although registration forms are scanned and made immediately available to anyone who needs access, it’s important that the software places them in the right order to ensure efficiency in HIM. White Memorial’s HIM department initially experienced some workflow disruption when coders attempted to work with scanned-in registration forms. “We had to redesign the file and rearrange the order of the images to allow coders to move through the documents quickly,” says Bryant. “Now they can immediately see the pages they have to code first without having to sort through images they don’t need. Most other staff members probably don’t care about the flow of imaged pages, but for coders who touch every single record, having them in a certain order can make a huge difference.”

Bryant recommends involving coders early in the implementation of forms-management software so they can provide input into the design and flow of pages.

Paperless Forms
While forms-on-demand software reduces the number of paper forms that must be produced and stored, a second type of forms management system saves even more space by creating totally electronic forms. Staff fill them out electronically and also distribute them electronically as needed. In facilities with e-signature capability, staff members or patients can sign forms without ever being printed.

“In this system, a coding query form, for instance, would not be sent to a physician in hard copy,” says McLendon. “Instead, the coder would select the form from an online menu, type the query, and send the form to the doctor electronically. The doctor can then complete the query and return it to the coder the same way or can print it out and complete it on paper.”

 McLendon estimates that more than 25% of hospitals are currently taking advantage of the cost savings of a forms-on-demand system, while totally electronic forms signed on PIN pads are less widely adopted, perhaps because the savings are not significant enough to offset the cost of the technology. He notes that the ability to create electronic forms physicians can complete electronically may not get much traction as hospitals focus more on EHRs.

Implementing Forms Automation
Setting up and configuring more than 1,000 forms in a forms-on-demand system for use by a large number of hospital employees is not difficult, but it is time consuming. “Implementation can take three to 18 months based on the size of the facility,” says Grzybowski “The average hospital has approximately 800 active clinical forms and many more nonclinical ones.”

“Carefully plan the automation of forms with regard to your plans for scanning completed forms into your document management system,” says McLendon. “You can roll out your forms management system first, but if it takes you a year or two to automate all the forms, you won’t realize the full benefits from scanning completed forms for that time period. Scheduling these initiatives should also take into account your plan for rolling out electronic health records, which will make some forms obsolete.”

To ensure a controlled rollout with interdisciplinary input, Grzybowski suggests appointing a forms committee. “Without a forms committee, hospitals may encounter problems such as ‘rogue’ forms that are introduced by vendors, physicians, or on someone’s home PC without proper approval or formatting; duplicate forms, both in number and content; excessive forms in an attempt to meet every potential situation for liability reduction; and external forms requirements such as state forms that are not under the control of the provider,” she says.

One duty of the committee is to establish standards for formatting both clinical and nonclinical forms—for example, to ensure that hospital and patient identification appear consistently in the same place on all forms. “The committee should also set standards around the purpose and content of forms,” says Grzybowski. “Each department should have an ‘owner’ who generates forms based on a full understanding of that department’s forms to make sure newly introduced forms and changes to forms comply with the forms committee’s standards.”

At Health First, a multidisciplinary forms committee reviews all forms in detail and ascertains whether they have been approved by subcommittees as necessary. “New forms or modifications to existing forms must be submitted to the committee for review prior to being used,” says Spillers. “The committee has defined templates for the forms, with standard headers and footers, fonts and sizes, bar-code types, and the like to make sure they work not only with the forms management program but also our scanners and the document management system. All patient demographic information is consistently placed in the same location in big bold letters to make it easy to read to avoid errors. Our risk management department also reviews the forms for consistency of patient identification and safety.”

Grzybowski suggests the following project management steps for automating forms:

• Inventory existing forms.

• Analyze the content of forms to ensure they are still relevant and to avoid duplication and redundancy.

• Identify any current processes that are not supported by a paper form but could benefit from an automated form.

• Delineate the workflow surrounding those processes.

• Research and identify a suitable software application for forms automation.

• Populate preprogrammed software (if provided by a vendor) or develop software in-house if desired.

“The more sophisticated programs today also incorporate content management and analytics of forms,” says Grzybowski. “Using natural language processing techniques, they might search for and spot inconsistencies in clinical forms. On the nonclinical side, content management might handle updates and revisions, for instance, to prioritize the updating of forms. Sophisticated software programs such as these allow you to manage your forms program with much more efficiency and payoff and force you to maintain your forms to a standard of compliance.”

• Roll out training and implementation. “This can be unwieldy because new forms will keep appearing and others will change while the process is under way,” says Grzybowski. “An external facilitator and guide will make it go smoother.”

If a hospital intends to implement both EHR and forms-management technology, Grzybowski recommends beginning with a clinical forms inventory and automating all the clinical forms. Then the hospital can either proceed to the automation of nonclinical forms or implement the EHR. Completing the automation of all forms first may be slightly more efficient, she suggests.

“Unfortunately, some HIM directors have not been as assertively involved in forms control and automation as they should be, possibly because other departments have taken the lead,” says Grzybowski. “HIM directors are in the best position to take an active role in leading the charge in forms management, whether it’s clinical or nonclinical forms. They have the most global view of the hospital’s processes and it’s a natural fit for them to chair the forms committee or take another leadership role to make sure the hospital realizes the full benefits of forms automation.”

— Alice Shepherd is a southern California-based business-to-business journalist specializing in healthcare topics.