August 20, 2007

Freed From Paper’s Weight
By Selena Chavis
For The Record
Vol. 19 No. 17 P. 14

Learn how three healthcare organizations unchained themselves from “the paper monster” by implementing an electronic document management system.

Whether it’s a first step toward the implementation of an electronic health record (EHR), a way to improve workflow, or a strategy for freeing up needed space, healthcare organizations are finding that document management solutions deliver the desired results.

Regulatory and accreditation pressures resulting from HIPAA and The Joint Commission—requiring a wide range of documents to be stored for specified time periods—have made paper storage strategies paramount as healthcare facilities seek to properly manage information. It has also created a paper nightmare for many facilities.

“No matter how much we expand, there’s never enough clinical space,” says Leah Conway, senior project manager with Baltimore-based Mercy Medical Center. “It was decided that we’ve just got to do something about this paper. [Document management technology] has really helped with the paper monster.”

While regulatory requirements may be one driver creating the “paper monster” in healthcare environments, industry professionals suggest that the overall push toward the implementation of electronic document management systems (EDMS) is driven by the transformation of IT occurring across the board. “It was one of many solutions as part of the entire IT plan,” says Tom Johnson, medical information systems manager with Pennsylvania-based DuBois Regional Medical Center (DRMC).

As healthcare environments move further into the realm of hybrid medical records, where data is recorded in paper and electronic forms, virtually every healthcare organization will be wrestling with the challenges of managing paper-based health information alongside more efficient, streamlined, and secure electronic data processes.

And the benefits of EDMS can be far-reaching, says Marsha Hunter, medical records director at Iredell Memorial Hospital in North Carolina.

“It has made a significant impact on our medical record department, ER [emergency room], billing, and revenue,” she notes. “With the automation, we were not only able to improve revenue, but it allowed me to free up needed real estate in the hospital.”

By providing a method for scanning, archiving, tracking, and managing images of paper documents, EDMS technology can help integrate numerous disparate information systems that would otherwise work independently of each other. Documents have the potential to be linked to transactional systems that previously would not have been able to access them, and many labor intensive document-centric business processes can be better streamlined.

The following case studies provide examples of how several healthcare organizations approached EDMS implementation, as well as best practice advice from the trenches.

Iredell Memorial Hospital
“We were fighting a losing battle in the emergency room,” Hunter acknowledges, noting that cleaning up significant revenue losses from lost records in the emergency department (ED) was the primary driver for EDMS adoption. “It seemed that we were missing a lot of the ED records before we could get them billed.”

The losses amounted to $40,000 per month for the 247-bed licensed facility that sees nearly 5,000 monthly ED visits. The staff would log in all emergency visits and reconcile them with patient charts at the end of their shift. After generating nearly 300,000 pages per month, ED staff often found they couldn’t reconcile the log with the patient records because paper records were lost.

“[Patient charts] just never would make it to the medical records department. Often, the records would stay in the ER for a month,” Hunter recalls, adding that while the ED was the initial reason for seeking document management solutions, the facility also recognized that it would be a step toward EHR implementation. “We do have some electronic processes in place. It’s definitely a portal to an electronic record.”

After choosing the digital document management system developed by Laserfiche, Hunter says Iredell saw immediate results in ED revenue, and the facility reduced paper by 80% through the automation of business processes. In addition, the hospital has automated chart creation, as well as eliminated physical copying and transport of records—ultimately expediting coding and billing and fulfilling its HIPAA and Joint Commission obligations.

Of all the benefits the facility has realized with revenue and workflow, Hunter notes that one of the best results has been the elimination of courier services for ED records. Located 50 miles from Charlotte, the facility previously had to make three copies of an ED record—one each for billing and quality, as well as a copy that would be sent via courier to the contracted physician services office in Charlotte.

With the EDMS implementation, Iredell physicians now have instant access to records through their own portal. “That was a great win for their quality and the way our hospital provided service,” Hunter says. “They love being able to review records online.”

The organization still maintains two years of hard copy documents because, according to Hunter, “that works well with our readmission rate.” Currently, the hospital realizes a 35% readmission rate, and more than 50% of its patients fall under the auspices of Medicare or Medicaid. “They do frequent the hospital a lot,” she notes, adding that the organization has also opted to keep some paper records because many doctors “have not totally given up the paper record yet.”

The Laserfiche program implemented by Iredell provides a direct interface with the Keane Patient Management System, which runs the facility’s patient accounting system. Hunter cautions that facilities need to be aware of their current and future needs when choosing EDMS technology, making sure that it will provide all the necessary interfaces with other patient programs. “If you don’t stay smart in all of this, you can cost your facility lots of money,” she warns.

Looking forward, Hunter believes that Iredell will always have some need for document management technology, even following the facility’s planned EHR implementation. “Of all of the hospitals I have interviewed [with EHR systems]—at the end of the day, 30% of the record is still paper, so they have to scan the documents,” she says. “I don’t think that will ever go away, so you need a system that is compliant and plays well with others.”

Mercy Medical Center
For Mercy Medical Center, space was the key driver for choosing document management solutions. But, according to Conway, the organization has realized many additional benefits since implementation. “It was definitely a space constraint issue,” she recalls. “We didn’t realize we were going to get the big benefit of improved workflow and less misplaced documents.”

The 280-bed Catholic healthcare facility is part of Mercy Health Services, Inc., which also includes the Stella Maris long-term/geriatric care facility, as well as a network of community health centers. Because the healthcare network’s two primary facilities used different medical applications—Meditech and Misys Vision—it was important to find technology that would easily interface with both systems.

According to Conway, the organization began its vendor selection process in 2004 and commenced a pilot program through technology vendor ImageNow that would cover records within accounts payable (AP), its breast cancer unit, and portions of medical records. “We wanted to see how the software behaved in a business and clinical setting,” Conway says.

The organization later went live with implementation that delivered immediate benefits in the labor and delivery departments, medical records, admissions, AP, and physician practices, according to Conway. Currently covering approximately 70% of functions, the technology has since been deployed to such departments as human resources, patient accounting, lab, radiology, scheduling, and the cashier.

“By making it all electronic, the results have been magical,” says Conway regarding efficiencies achieved throughout the organization.

Conway says the organization chose to first deploy the technology to the labor and delivery department because “[it] represented the biggest monetary risk” if the hospital had difficulty locating a record. “Records were being shuttled all over the hospital,” she recalls. “We were doing a pretty poor job of handling prenatal records.”

Before the initial rollout, Conway says the organization made a strategic decision to avoid the process of “back scanning” records, instead taking a from-this-day-forward approach to scanning records. “The amount of time it would take to scan [past record data] was significantly higher than using the status quo,” she says, referencing the results of a cost-benefit analysis suggesting personnel labor for scanning would be greater than continuing with storage and retrieval fees. “The time it was taking to look things up was way less. We would rather spend our time rolling out the technology to new departments.”

The greatest difficulty encountered during the roll-out process rested with quality control of data entry, recalls Conway. “The human factor is biggest of all,” she says. “I think it takes a multipronged approach to combat the problem.”

Conway suggests that data entry personnel have a clear understanding of how the data flows downstream and where their role fits into the big picture. An incentive program for doing well doesn’t hurt either, she adds.

Allowing for a full-time position to accommodate scanning needs is also important for successful roll-out. “There aren’t scanning fairies,” she quips. “Having a dedicated resource to do the scanning, quality control, and indexing is very important. We have clerks who do nothing all day and all night but scan records.”

DRMC
In 2004, DRMC received a $1.5 million grant from the Agency for Healthcare Research and Quality to research the effects of providing care with the aid of an EMR system. The project resulted in the development of a five-hospital regional health information organization, with the goal of sharing secured medical records information over a five-county area serving 174,000 patients.

According to Johnson, the benefits of document management technology were best implemented at the 214-bed hospital in conjunction with this EMR initiative. “Document management in itself would lack a lot of the intelligence found in the EMR,” he emphasizes.

The facility sought to focus on a number of core measures, including the availability of records at the point of contact, increased productivity, improved backlogs, lowered accounts receivable days, and the ability of workers to telecommute, “especially in areas that are hard to recruit, such as coders,” Johnson notes.

Michelle Montowski, a health information systems analyst, says the facility was able to use McKesson’s Horizon Patient Folder to automate 50 processes with 250 workflow intelligence cues built into the system. “As soon as a record is scanned in, it is automatically routed to the department that needs it,” she says, noting the resources available through the full EMR package allow that to happen.

In terms of measurable results, Johnson says the organization’s abstracting backlog went from $500,000 to less than $60,000 in less than three months. Along with these efficiencies, DRMC was able to decrease staffing in its HIM department by approximately one half, refocusing staff time to other areas of the hospital.

“That whole workflow rules engine creates great efficiencies,” he asserts. “You scan in all these documents, and then you say, ‘Great, now what do I do with this information?’ The ability to customize workflow is real value.”

Montowski suggests that during the rollout period of EDMS technology, it’s a good idea to “go ahead and throw staff at HIM. You are definitely going to wreak some havoc when you go live.”

It’s also imperative for HIM departments to “stick to their guns” after the go-live to make the changes a realistic part of operations. “Once a record was scanned, it was not to leave the department again,” she emphasizes.

Johnson recalls that physician buy-in was an important component to the overall implementation strategy and that the organization took a top-down approach. “We have a very strong chief medical officer,” he says. “Physicians were relatively negative at the beginning, but the overall satisfaction [with the end product] has been great.”

DRMC also initiated a plan where physicians would receive one-on-one training. “Really, it’s fear. They need to see that it’s going to save [them] time and not cost [them] time.”

— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications covering everything from corporate and managerial topics to healthcare and travel.