March 19, 2007

One Scan at a Time: Moving Paper to Electronic
By Aggie Stewart
For The Record
Vol. 19 No. 6 P. 12

Visit four healthcare organizations that developed scanning strategies designed to meet both short- and long-term goals and learn how the process is redefining HIM’s role.

For many provider organizations, using document imaging as a bridge to an electronic medical record (EMR) offers the best solution to achieving a more fully digitized record until more effective, enterprisewide solutions to electronic documentation capture can be implemented. Not a plug-and-play component of an EMR system, document imaging requires sound processes and practices for an organization to achieve not only its document imaging goals but also its larger EMR and health data goals. It’s no small task, to say the least.

Nonetheless, some organizations are meeting the challenge it presents by aligning short- and long-term goals with a larger strategic vision for managing information. “HIM directors need to become very active in the entire information management strategy for their organization,” stresses Rita Bowen, MA, RHIA, CHPS, HIM director and privacy officer for Chattanooga, Tenn.-based Erlanger Health System. Bowen believes that addressing key questions is part of building a coordinated, comprehensive, enterprisewide information management strategy. “How do we build the credibility to the data quality from the get-go?” asks Bowen. “How do we improve our processes? How can HIM be used, not so much as a department, but as an integral role in every department?”

Chris Meyers, RHIA, director of patient financial services/HIM for Phoenix-based Banner Estrella Medical Center (BEMC), sees this more comprehensive envisioning of information management as part of her organization’s commitment to patient-focused care. BEMC is part of Banner Health, a nonprofit healthcare system that operates in seven states in the West and Southwest. When BEMC set out to design its scanning process, “we said that we needed to do whatever it takes to get the [scanned] documentation at the bedside during the patient’s stay,” says Meyers, who was brought on board as BEMC’s HIM director to help design and implement its EMR.

In the ever-evolving world of EMR development and implementation, short- and long-term goals are hardly static. Because technology rollouts can be staggered, a flexible yet tightly coordinated and overseen strategy for document imaging that balances immediacy and far-ranging concerns may be needed.

That was the case at Southern Illinois Healthcare (SIH), a three-facility healthcare system comprised of a small community hospital, a larger hospital that serves as a regional medical center, and a critical access hospital, all in close proximity to one another. Although each serves a mostly rural population, facility size, patient volume, and services vary from one hospital to the next.

The scanning process developed for the SIH system needed to accommodate, among other components, a staggered schedule of interface rollouts for various areas within each facility; SIH scans only those documents not yet electronically fed into its EMR via an interface. For SIH, end user considerations took on great weight in its process design. “Several of our medical staff practice at all three facilities,” explains Marcia Matthias, RHIA, SIH’s corporate director of HIM and privacy officer. “We did not want them to see any variation in what they saw in the system or the expectation of when they saw things in the system.”

California-based John Muir Health faced a similar situation when it decided to design and implement its document imaging process. Two large acute care hospitals within a 10-mile radius comprise John Muir Health: one 321-bed campus in Walnut Creek and a 250-bed campus in Concord. Document imaging was being implemented as part of a systemwide EMR implementation.

According to HIM Director Linda English, MPA, RHIA, their conditions prohibited an across-the-system rollout of a document imaging process, so priorities had to be set for a phased implementation. Given the combined size and patient volume of both facilities, “we needed to be very realistic about what we could take on initially,” says English. John Muir’s chief information officer also wanted “the project to shine,” says English, which meant that an overall successful document imaging implementation would need to be built from the incremental success of each phase.

Guiding Principles Facilitate Success
While the overarching objective in implementing a document imaging process may be the conversion of paper to electronic documentation, what are the practical, day-in, day-out objectives? It’s important to identify these clearly and explicitly, since these objectives should drive process development.

For example, before beginning to flesh out its process, BEMC identified four guiding principles that helped shape its day-to-day process. These principles emerged from its commitment to patient-focused care. “We used the guiding principles and decided what was important to us,” explains Meyers. “And that was a chartless clinical environment, documentation at the patient’s bedside, concurrent e-HIM processes, and [the ability] to offer a remote working environment for HIM staff.” According to Meyers, this last objective has enabled BEMC to create the ability for all HIM functions to be accomplished remotely when necessary or desirable.

BEMC provides a unique function in the Banner Health system. A two-year-old facility, BEMC serves as the system’s hospital for the future and learning lab for new technologies and best practices. As a new hospital, it never had paper records, and the system’s leadership capitalized on that by planning to open the hospital with a fully operational EMR. “Our process for implementing the EMR and best practices as a system is called Care Transformation,” says Meyers. “The hospital’s scanning process was developed as the Banner Health enterprise model for document capture [as part of the EMR],” she continues. “What we do at BEMC will be rolled out eventually to all 19 of our facilities.”

Using its guiding principles, BEMC created a concurrent scanning process organized around a distributed scanning process. “We didn’t want a postdischarge scanning methodology because that doesn’t benefit our patients,” explains Meyers. “What benefits our patients is a nurse being able to pull up any document at the patient’s bedside, whether it’s originally captured electronically or whether it’s captured via paper and entered into the patient’s record using digital technology so that it’s available at the patient’s bedside.” BEMC set a 30-minute standard for bedside availability of scanned documents: the turnaround time typically averages between 10 and 15 minutes.

Distributed, concurrent scanning facilitates a faster turnaround time and allows HIM staff to accomplish higher-level functions, such as quality and accuracy checks, more expeditiously. “Our HIM department functions very differently from other HIM departments with respect to scanning—I’m not sure anyone else does scanning the way we do it,” comments Meyers. “From my perspective, capturing the document can be done anywhere.”

BEMC scans documents in real time at the point of origin (eg, admission, inpatient unit, lab). HIM staff receive scanned documents electronically in batches, at which point they perform a quality review, ensuring that the scanned image is high quality, and that it’s been assigned to the right patient and account number. Upon completion of the quality review, HIM releases the document to the EMR.

Erlanger’s long-term goal was to create an electronic record that would have a high degree of customer—particularly physician—acceptance and use. “We knew we couldn’t wait [to implement an EMR] until the record could be 100% electronic, so we knew we’d have to scan,” explains Bowen. “But from the outset, we considered our imaging solution truly a bridge solution to get there, so we could get the doctors used to using the online record.”

When Erlanger went live with its EMR last fall, only 30% of the technology was electronically generated; the remaining 70% needed to be scanned. While Bowen anticipated the proportions to change fairly rapidly—she expects the record to be 50/50 by the end of this year—she also knew Erlanger would need a scanning process that could stand the test of time, but, more importantly, one that met customer expectations for turnaround time.

Consequently, Bowen made it a priority to meet with customers, primarily physicians, to identify turnaround time expectations for scanned documents. Because they wanted scanned information to be available for rounds the morning following discharge, Bowen understood that her process needed to be built around meeting the turnaround time, which meant reorganizing staffing. “We shifted 60% of our workforce to second and third shift, so that we could meet our customers’ demand for turnaround,” she says. Part of Erlanger’s process involves meeting standards for emptying work queues and nursing unit accountability for making the record available to HIM for scanning. And while scanning remains largely centralized in HIM, the registration area scans many documents captured at the front end, such as insurance cards, durable power of attorney, and advance directives.

Ongoing Forms Management
A successful scanning process necessitates not only well-designed forms but also ongoing forms management. An inventory of forms needs to be maintained and criteria developed to guide form design and redesign efforts. Forms best practices also include assignment of a bar code to each form from the outset of the scanning process to enable auto-indexing. “Don’t be penny-wise and pound foolish and start a document imaging process without a good solid forms management process—unless you can afford the labor to manually index documents,” advises Meyers. “Lack of bar codes equals labor—there are no two ways around it.”

Forms management also needs to include any downtime forms used, eliminate multipart forms, and ensure that all old forms are purged. Downtime forms in particular can be easily overlooked when designing and redesigning scan-ready documents prior to go live. As with any other form used, they need to be free of design issues, assigned a bar code, and run through system and process testing prior to go live. “We found out the hard way that none of these forms were run through forms management to see whether they met our scanning criteria,” says English, “and they weren’t assigned bar codes.” With more than 1,000 active forms in use at John Muir, forms management is an ongoing challenge. “Sometimes we have old renegade forms show up,” says English. “This is an obvious problem because they have no bar code label on them. So we have to stop and correct the problem.”

Replacing an addressograph patient ID with barcoded patient ID labels represents another forms best practice. Smudging and other stamping quality issues make addressograph information difficult to scan clearly. “In the long run, using barcoded patient ID labels not only contributed to scanning efficiency and accuracy, it also helped improve patient safety,” notes English. At John Muir, all medication orders are scanned in real time into the Pyxis system. Barcoded patient IDs enable the pharmacy to better ensure that the right patient receives the right medication.

John Muir realized another collateral benefit from real-time scanning of medication orders with barcoded patient IDs: decreased delinquency rate on signed verbal orders. Once a medication order is scanned into Pyxis, a copy of the order prints in the HIM department. HIM staff scans the order and releases it to the EMR. This allows verbal orders that need a signature to be placed into a queue to be signed by the appropriate physician. Because the EMR system can be accessed anywhere, these orders are signed in a more timely manner. “We saw our deficiencies drop incredibly and quickly,” says English. “And it’s because we scan [these orders] concurrently rather than postdischarge and manage the physician notification and signing processes electronically.”

HIM Role Evolution
As bridge technology, document imaging affords HIM staff the opportunity to develop higher level computer and other professional skills, such as critical thinking, communication (written and oral), and data management, reporting, and analysis. Many HIM directors, such as Bowen, not only encourage but provide incentives for their staff to pursue continuing education, degree work, and certification. “We worked with the local junior college and encouraged many of our staff to go back to school—and they did,” says Bowen. “We really pushed them to pursue an RHIT degree. Now they want to use the skills and knowledge they gained, and the movement toward electronic documentation via scanning allows them to put those new skills and knowledge into action.”

Matthias stressed the importance of increasing Windows-based computer skills with her staff and strongly encouraged them for more than one year prior to go live to take advantage of the classes offered through the IT department. In preparation for EMR and document imaging implementation, Matthias restructured and reclassified all HIM roles, which were made consistent across all three SIH facilities. Clerical jobs were eliminated and replaced by a variety of technician positions. Existing staff were then required to apply for these positions; part of the application process included a computer skills test and assessment.

“We knew that if staff couldn’t use the computer, they wouldn’t be fit for any of these jobs,” explains Matthias. Consequently, some HIM staff chose not to remain with SIH or transferred to other departments; those who stayed made the transition to new workflow, new roles, and new schedules with a great deal of satisfaction.

Roles also change regarding relationships with other departments or areas within the organization relative to the scanning process. Bowen points to the relationship between HIM and IT in particular, especially where cold feeds are concerned. “Someone needs to monitor cold feeds, which hasn’t always been done in the past,” she cautions. “When the record becomes electronic, you want to make sure this is done daily and that any discrepancies are resolved and that HIM knows how they’re being resolved because if you’re asked in court to validate the authenticity of a record in question—and cold feeds are a part of it—you’ll need to know how to answer that question.”

Interdepartmental communication becomes especially critical when electronic documentation is rolled out in a staggered fashion, as is the case for many healthcare providers. Organizations that choose to do centralized scanning need to stay on top of how information is coming in because it not only affects prepping but also whether what comes in electronically replaces or appends a scanned document.

For example, at Erlanger, electronic nursing documentation rolled out incrementally, which raised the question of whether the electronic documents replaced or appended the scanned documents. “Because nursing documentation was rolling out incrementally, electronic documents really needed to append, not replace, scanned documents. But that wasn’t happening—it was replacing imaged documents in nursing units that had electronic documentation,” explains Bowen. “We discovered this in the QA [quality assurance] process and had Technology Management change the system so that these electronic documents appended scanned documents.”

According to Bowen, this increased communication helped enhance understanding by all parties of the processes involved and how each department or area contributes to completing the process. “The need for the front end to talk with the back end before it initiates a process is really vital,” she stresses.

Enhanced communication and understanding underlies English’s conviction around the importance of cross-training and being clear with staff about turnaround time expectations. “Cross-training is essential,” emphasizes English. “The more each staff member knows about the individual processes and turnaround expectation, the better, because conditions change.” English refers to the practice of moving staff among functions as patient volume necessitated. Not only do HIM staff find this arrangement more interesting, it helps them understand the bigger picture of EMR and how it functions in their organization.

“The level of staff job satisfaction has increased,” explains Bowen, “not only because pay increased, but because they feel like they’re really contributing. They’re not just filing the pieces of paper; they’re starting to see how it all fits together—so they love it.” As they recognize what links together in the documentation and what’s required in the record, Bowen’s staff is developing the skills necessary to validate record completion, which makes them a more useful resource within the organization.

Bowen knows that while HIM roles will continue to change over time as the need for scanning decreases, quality initiatives related to record and data quality will expand. “It’s also important to look around the hospital to see if there are other areas that can use these talents,” she says. “You have to continue to be visionary and ask where HIM can make the most impact.”

As healthcare becomes more fully electronic, Bowen contends that HIM must be more closely involved in ensuring data quality from the outset, whether the data originates in the clinical areas or administrative areas, such as registration. She also believes health information needs to be managed more broadly as a strategic resource. According to Bowen, the key to this kind of shift lies with HIM leadership being viewed as HIM strategists, a change she is pursuing in her own organization.

— Aggie Stewart is a freelance writer and editor, specializing in HIM and HIT. She also serves as consulting editor of Health Information Management Manual, 2nd edition. She can be contacted at s-p-s@earthlink.net.