December 3, 2012

Document Management Challenges
By Susan Chapman
For The Record
Vol. 24 No. 22 P. 18

HIM departments must clear several hurdles to incorporate hard-copy documents into an EHR.

Although healthcare facilities are transitioning quickly to EHRs, HIM departments must still manage volumes of paper. Documents such as handwritten notes, patient consent forms, patient instructions, advance directives, powers of attorney, and referral records present an organizational challenge that many facilities are feverishly working to overcome.

Managing the Paper Trail
“It really is a challenge,” says Debra Primeau of Prime Health Information Consulting (PHIC). “There are many different EHR systems—both outpatient and inpatient—and they may not always interface, so integrating these various paper documents can be difficult.”

Hospitals have strict policies in place as to what types of documents can be sent to an EHR. Primeau notes that many facilities scan these documents while others use tablets that enable the documents to exist electronically and allow for digital signatures.

“Sometimes this process requires additional manpower,” Primeau explains. “For instance, in the case of inpatients, all patients have some documentation that comes from other facilities and physician offices, and these need to be scanned.”

PHIC’s Nicolet Araujo recalls the mayhem that was frequently prevalent in the medical records department more than 20 years ago. “There were stacks of paper everywhere and even though the organization was scanning based, they had such a low comfort level with the process, they would scan and keep the paper, too,” she explains.

Fast-forward to 2012, and Araujo says the situation hasn’t changed much, noting that while there are many EHR solutions, “We don’t have the ultimate solution yet, and it’s frustrating considering the advances in other industries.”

As organizations move toward EHR documentation, using tools such as speech recognition and natural language processing, those paper-based forms still exist. “EHR vendors often don’t consider those documents, leaving clients to come up with solutions on their own, yet the technology already exists to correct this problem,” Araujo says.

She believes there is a two- to three-year window before healthcare organizations will garner true efficiencies in an electronic environment littered with paper. “If they don’t develop new electronic processes for handling these documents, sometimes facilities are forced to deal with extra paper with a knee-jerk reaction,” she says. “This can easily lead to a need for additional staff. It also creates an inefficient workflow.”

Among the types of documents Araujo cites as being particularly problematic are advance directives and powers of attorney. “Some paperwork, like consent forms, for example, exists solely for legal reasons,” she notes. “A clinician doesn’t need some of these for day-to-day work. Advance directives and powers of attorney, however, must be front and center. These documents come into the hospital in paper format and either never make it to the medical records department or end up in a drawer there. Sometimes they aren’t where they need to be and/or are inaccurate. The EHRs don’t yet simplify these issues.”

Barbara Hinkle-Azzara, RHIA, vice president and general manager of Meta Health Technology, says managing paper documents varies widely among healthcare organizations. “Many facilities and practices are still generating a number of hard-copy documents or printing documents and scanning,” she says. “Progress notes are one of the most important components of the patient record, and many EHRs still don’t have progress notes electronically. Facilities need to consider a solution that can integrate with the EHR to incorporate these remaining hard-copy documents so they are available in the electronic record.”

Deborah Kohn, principal with Dak Systems Consulting, views the issue differently, noting that many paper documents, such as consent forms, can exist as digital documents and be signed digitally. “The evolution of EHRs is toward the digitized signature,” she says. “Whether the EHR uses a keypad, as we commonly see in the grocery store, or a tablet, any paper form that requires a patient signature can eventually be digitized.”

Kohn adds that physicians and healthcare workers are increasingly using digital signatures that rely on a card swipe and a password. “Even less sophisticated systems have this capability,” she says, “and they require no more training or resources at all.

“Should the occasional paper document need to be scanned, scanning is not that big of an issue,” Kohn continues. “Once the healthcare worker scans the document on a multifunction device, for example, she can save it as a PDF and upload the document into the EHR. Occasional document scanning doesn’t significantly impact workflow.”

Version Control
A document management system (DMS), which complements an EHR, can enable organizations to keep track of versions of documents as they change. For example, a DMS can monitor EHR components such as dictated physician notes that move from the original recording to the transcriptionist and back to the physician for approval.

“A DMS allows for tracking of several versions of documents,” Primeau says. “Physicians write a report. A newer report, an amendment, can then be made, and that attachment or amendment can be made available in the EHR with the date entered and date amended.”

According to Hinkle-Azzara, a DMS can assign versioning automatically. “A new version can be scanned in, and the system can identify it,” she says. “From that point, there are several methods available to compare and ascertain whether it is a new version of a document: The system may automatically recognize it; a person can review and verify it; or a physician can electronically sign the document. After such verification, the DMS will assign a new version to it.”

“If the capability exists for version control within the system, the DMS will recognize which version is the most recent,” Kohn says. “For example, if the document name is the same, one document will be noted by the system as version 1, the next, version 2. The system shows you only the last, most recent version. It’s important that the system retain every version so that you can have an audit trail, but only system administration has access to earlier versions.”

If employed correctly, a DMS can provide many features associated with an electronic system. “Document management systems is a process by which you manage your documents, but it’s much like your electronic or paper calendar,” Araujo explains. “It’s only as good as what you input, so if you don’t use your DMS system or use it improperly, it’s not going to be of great benefit.”

It’s important to know how a DMS is organized, whether it’s easy or difficult to locate documents, and whether the system is incorporating all documents. “Essentially, DMS is a scanning system, so you have to consider what format the documents need to be in for the system to accept them and does it take an electronic feed of what would be produced as a paper document,” Araujo says.

Gaining interoperability between a DMS and EHR is key. “In the case of scanned documents, if you have an image-enabled EHR, the EHR and DMS should interface seamlessly,” Kohn says. “Version control should exist in both systems. Sometimes it doesn’t, but it’s an important capability.”

State and federal laws mandate how the compilation of documents that comprise the patient medical record is created, who creates it, and how it is maintained. Because nothing can be destroyed or reconstructed during certain time parameters, facilities must have the ability to store multiple versions and maintain version control.

For example, take a file folder that is updated six months later. “You place the newer version on top, but you don’t destroy the original version,” Araujo says. “You have to be able to look at older versions because you need the document for reference and legal purposes. The record tells a story over time, and something in the past could become relevant again. Because of this, we have to consider how long we keep that story.”

Generally, retention laws state that a record must be preserved for 10 years. However, when a record becomes electronic and is no longer visual like its paper-based counterpart, information becomes comingled, and it’s difficult to separate old information from new. “There is no longer a clear dividing point on when and how to purge,” Araujo says. “Storage is cheaper than making a costly error. But then consider do you want to have documents that are 20 to 30 years old that can be accessed and referred to? Legally, that can become a challenge if, for instance, a court case arises and those records are still accessible.”

The Benefits of Bar Codes
Bar coding continues to play a significant role in EHRs, with its use making it easier to track paper documents and patient interactions. “You can place bar-code labels on a piece of paper and wand-scan it into the EHR,” Primeau says. “From that process, you can validate that the bar code matches the patient and that piece of paper. The bar code stores patient demographic information, and it allows the staff to track paper that can’t be input right at that time.”

In EHRs, bar codes come in handy when dispensing medication, helping to reduce the chances of dosing errors. “Bar codes help ensure patients are receiving medications properly,” Kohn says. “A nurse can enter a patient’s room and find out whether a patient needs her medication, for example, even if she’s sleeping. The nurse ‘wands’ the drug label and the patient’s wristband. The bar code then recognizes the information, just like in the grocery store when the scanner recognizes that the cashier is scanning a box of Cheerios. The bar code stores the patient information and the contents of the bottle of medication. Through the process of wand-scanning the patient and the medication, the information is entered directly into the EHR.”

While bar codes have the least margin of error, an entire analog form cannot be bar coded. Scanning is generally a better choice to ensure that staff can view specific information written on a document. However, with scanning, data cannot be retrieved from that document.

“All scanned documents do is give you a picture of the document,” Kohn says. “Some systems can look for check marks and other markings. Recognition software that has that capability has a larger margin of error than bar-code scanning.”

Continuing the Transition
Healthcare professionals note that although it has its share of obstacles and uncertainty, the transition from paper to electronic records is an interesting process. “We’re in a transition state right now,” Primeau says, “and transformation is always an exciting time.”

— Susan Chapman is a Los Angeles-based writer and author.