March 28, 2011

Document Management and Meaningful Use Requirements
By Robert N. Mitchell
For The Record
Vol. 23 No. 6 P. 20

An argument can be made that the scanning of paper records must play a larger role in the federal plan to promote EHR adoption.

What was the federal government thinking? As providers are being nudged to convert paper medical records into EHRs, some healthcare leaders are wondering why there weren’t incentives built into the meaningful use requirements to account for the cost of converting existing paper records into digital formats.

Currently, EHR incentive funds are designated for office-based physicians and hospitals that treat significant numbers of Medicaid and Medicare patients and meet the incentive criteria as defined by the HITECH Act, namely to become meaningful users of certified EHR systems. However, the incentives do not reward providers who convert their current paper files to digital records. It’s a sticking point for those who view the process as an essential component on the road toward a more electronic healthcare system.

Last year, Iron Mountain, a Boston-based information management services company, called on the Centers for Medicare & Medicaid Services (CMS) to expand the scope of meaningful use incentives to reward providers with federal subsidies for digitizing paper records and scrubbing patient databases. Iron Mountain had made its recommendation in response to the CMS’ Notice of Proposed Rulemaking.

Incentives for Digitizing
In comments at that time, Ken Rubin, Iron Mountain’s senior vice president and general manager of healthcare, told the CMS, “In hospitals today, managing patient records consists of an inefficient patchwork of systems, processes, and decisions. If a hospital has poor processes for storing and managing hard-copy medical records, simply digitizing them will only add to the mess, not help solve it.

“Health systems that first streamline their paper storage and workflows for handling records not only establish the right framework for an EHR, [but] they can also find as much as $1 million in savings to help fund their transition to electronic records,” he added.

While the comments fell on deaf ears, the point was made that the conversion to EHRs will occur as an evolutionary process over years. “So, for the better part of a decade, it’s reasonable to expect that hospitals and doctors’ offices will be living with a combination, or hybrid, where some information will be electronic and others will be paper based,” Rubin says.

Iron Mountain believes that if more providers converted to digital technology (ie, the orderly scanning of documents such as doctor’s, nurse’s, and medication notes), it could reduce the healthcare industry’s reliance on paper and accelerate EHR adoption.

“Absent that, we’ll be living in a no man’s land where some of the patient information is electronic and some is paper based. Part of the ARRA legislation, the HITECH Act, has incentives to implement EHRs, but there isn’t any incentive to convert paper to digital. … There are no specifics around support services such as scanning,” Rubin says. “For that matter, data protection is in the same category. We see thousands of doctors implementing an EMR and not having the understanding to properly back up data who may be putting medical information at risk. We think that this should all be part of the definition for caring and feeding of an EMR.”

John Fontanetta, MD, FACEP, chief medical officer for EDIMS and chairman of the emergency department at Clara Maass Medical Center, part of Saint Barnabas Health Care System of New Jersey, says the purpose of a digital record is to make pertinent information readily available. Besides deciding what types of data should be included, it’s equally important to know what should be left out, he says.

“When you go to a clinician and ask what are the important things, he or she wants an in-depth understanding of the patient’s medical problems, whether they have been resolved or continued, any medications, allergies, a surgical/medical history, and test/lab results,” Fontanetta says. “The clinician really doesn’t care that the patient, who is now in her 40s, had a well-baby visit when she was 2 years old. That’s not pertinent. However, it would be pertinent if the patient, when she was 2 years old, had an allergic reaction to penicillin.”

The Ideal Incentive
Fontanetta says condensing the amount of information that’s exchanged would make the digital record system more effective. “I think some kind of synopsis would be very helpful. Doctors do that all the time,” he says. “For example, if I send a patient to an orthopedist, he doesn’t send the entire medical record back. Instead, he sends a synopsis of the visit. That’s what I want to know. But one of the problems we’re going to have in the digital age is that we’re getting a plethora of data that we can’t possibly look at in its entirety. We need a smarter way to bring information forward in a concise way.”

To advance that concept, Fontanetta says incentives are needed. “My recommendation would have been to incentivize for creating a synopsis of the patient record. For example, let’s say I am a pediatrician and had treated a patient for 12 years. What really would be nice is if I could create a one-page, unified synopsis,” he says.

John King, chief operating officer at EvriChart, a document management company based in West Virginia, says the concept of meaningful use is difficult for many providers to understand because “there’s such a disparate level of readiness.” He’s also a proponent of incentivizing healthcare organizations to convert from paper to digital records.

“It’s especially important for when a patient requests a copy of their record and eligible providers have 48 hours to turn that around,” King says. “It’s difficult to do if you have records strewn about in various storage units or filed in paper in the HIM department. It’s very germane to meaningful use to have an incentive to have that available. It’s an important part that the public is just now becoming aware of. … The HIPAA rule gave providers 30 days to retrieve the patient’s information. That’s huge: one month vs. two days. I don’t know whether 102 days, much less two days, would be enough time for a facility to be able to locate, aggregate, scan, and put into an electronic format all the patient is entitled to.”

Ironically, according to Evrichart Chief Information Officer Tony Maro, healthcare organizations can meet all meaningful use criteria yet still not be able to provide a patient with a digital copy of his or her medical record within 48 hours.

Tom Griga, global healthcare manager at Cincinnati-based Cintas, also backs the idea of an incentive to transform paper-based clinical information into the digital formats needed to reach meaningful use.

“Since the HITECH Act is already in place, which pushes the use of EMRs and the future vision of the EHR, EMR vendors typically do not place importance on day-forward scanning,” he notes. ”Historically, most EMR vendors have not been able to ingest the large amounts of data necessary to populate the digital records nor do they have programs in place to store such large amounts of data. They do a great job placing current critical information, also known as standardized data, into the systems but don’t address the importance of the historical data. When a patient presents, the physician/clinician will want to know the entire patient’s history.”

Paper to Digital Conversions
The most common requests for patient information, whether it’s in a paper or an electronic format, include discharge summaries, physician and nurse notes, operation notes, and lab/radiology results.

“A smart hospital is wise to plan a year backward, maybe two, to make sure those paper records are either accessible on their campus within a storage area or from their vendor who can turn around that information in a timely manner,” King says. “Because our software was written from the ground up, we can typically turn around a request within 20 minutes. We send our client only the three or four documents they’ve requested, nothing more.”

Once the reality of getting paper records converted to digital is achieved, other challenges remain. For example, how is legacy data handled to avoid it being “orphaned”? Recently, a hospital encountered a problem with data being left behind. After replacing its radiology department system and all radiology reports that were not in the paper charts because they were now considered part of an EHR, a staff member noticed patient files remained on the server. When questioned, the EHR vendor told the facility it would not be loading those records into the system.

 A provider has several options to remedy such a situation, Maro says. “You can run the system parallel until the records can be destroyed, which may be another 10 or 15 years or a lifetime. Or the other option is to export that orphaned data to get it into the paper chart,” he says. “That’s going to be an ongoing challenge with EHRs when you convert one system to another. There will always be some sort of data that’s left behind and just doesn’t mesh. What are you going to do with that? … This speaks to the holes in planning and implementation that arise as a matter of course as EHRs are implemented.”

According to Griga, among the first things a healthcare organization must do when converting from paper to digital is to devise a strategic plan that addresses all areas of care. At the same time, a physician champion must be identified.

“This needs to be someone who understands the importance of a digital historical perspective and exactly what is needed from a preloading standpoint,” Griga says. “When considering what to convert and how, it is critical to match the current EMR vendor’s information and augment it in such a way to add significant value to share across the organization. This information sharing is very powerful in patient care and treatment and can differentiate a healthcare organization from its competitors for many years to come if it is addressed correctly.”

— Robert N. Mitchell is a freelance writer based in King of Prussia, Pa.