6 Optimization Strategies for Electronic Document Management Systems

Section 6.9 Optimize

Optimization Strategies for

Electronic Document Management SystemsMany health care facilities preparing to adopt an electronic health record (EHR) have paper-based records for those they have treated. As part of your chart conversion and pre-load planning, you will need to determine whether to keep the paper records, scan all of these records, scan only records for active clients, or scan only parts of active clients records. Understanding the options for scanning and other forms of document managementand preparing to use such systemshelps manage the scanning process and supports use of the scanned record content.Time needed: 4 6 hours

Suggested other tools: Section 2.4 Visioning, Goal Setting, and Strategic Planning for EHR and HIE, Section 2.6 Workflow and Process Redesign for EHR and HIE, Section 2.13 Chart Conversion and Pre-Load Planning

How to Use

1. Review your chart conversion and pre-load planning to determine the potential size and nature of your scanning project.

2. Review the types of electronic document management systems (EDMS) to determine which type is most suitable for your facility.

3. Develop a plan for implementing EDMS.Types of EDMS

Different types of EDMS provide a continuum of features and functions, from simple to sophisticated. The following are the types of EDMS used most frequently in health care: Document scanning is performed using a scanner with scanning software that scans the document and enables it to be moved into a folder on a computer. The individual performing the scanning saves the scanned image of the document as a file and then saves it to an appropriate folder. This approach is satisfactory for occasional scanning, but is too time consuming for scanning health records in bulk (such as for scanning all archived records). Each document in a record could take 15 to 30 seconds to prepare, 15 to 30 seconds to scan, and 30 seconds to a minute or more to index (for a total of one to three minutes per page).

Electronic document management systems (EDMS) help manage the indexing and filing of documents. This type of system is used for bulk scanning to archive and occasionally to retrieve scanned records. It is the most common form of scanning in health care. Within EDMS there are various levels of functionality: Basic indexing support is achievable using more sophisticated software that supports reading a leading separator sheet and sub-header separator sheets for each type of document (e.g., notes and orders) placed throughout the set of documents or record.

Automated indexing support use barcodes placed on each document that designates who the record belongs to and the type of document. Barcoded labels can be run for each record to be placed on a document. Labels can also be acquired to designate type of document or forms can be printed with the barcode designating the type of document so only names needs to be added. Software places each of the documents that are scanned into the appropriate folder and arranges the documents according to type. If the date each document was created is on the barcode label, the documents can be filed in date order within their type. Optical character recognition can also be used for indexing. The more indexing incorporated, the more time it takes to prepare the documents for scanning, but the easier they are to retrieve later.

Electronic feed of documents is a feature of EDMS that is important if your health professionals use dictation, receive electronic faxes (e-faxes), and/or receive email that need to be incorporated into your EHR. The ability to transmit the voice file, transcribed document, e-fax, or email directly to the EHR is a significant time saver rather. Alternatively, you have to print these out and scan them back into your system. In the past this functionality was referred to as computer-output to laser disk feed (COLD-feed). Today most of the electronic feeding of documents is performed on magnetic disks, but you may continue to hear references to COLD-feeding.

Workflow support is another feature of document management software. This enables the facility to set up rules for processing various documents. The software alerts a staff member to retrieve documents designated for a specific type of processing. For example, if certain documents should be directed to a person who assigns diagnosis and procedure codes for billing purposes, the workflow software directs that person to the applicable records. Workflow support is very useful if document scanning is the primary means of storing active records. More commonly, the EHR itself provides workflow support. Electronic content management system (ECMS) incorporates the above-described functionality and also is able to designate content to be read and processed by the computer. There are two ways to achieve this. On a text document that will be scanned, a few items of content may be designated with a barcode or optical character recognition to be extracted by the computer for subsequent processing. For example, if you wish to run a report on most frequent condition treated, the most frequent condition (or diagnosis code) would be extracted by the computer. More often, an e-form is used in ECMS. This allows extraction of data from the entire form for collection and processing by the computer. The e-form may include a mix of barcodes, optical character recognition, object mark recognition (bubble forms), and intelligent character recognition/handwriting recognition and/or speech recognition.

ECMS can be very useful when coupled with an EHR. For example, you could ask an individual to complete an e-form questionnaire in the waiting room. The questionnaire is then scanned, making the data readily accessible in the EHR. For this to be achieved, the ECMS software must be compatible with EHR interoperability standards, especially Health Level Seven (HL7). (See Section 1.3 Interoperability for EHR and HIE). Increasingly, tablets are replacing e-forms; the individual in the waiting room would be handed a tablet on which to complete the questionnaire, which would be designed as a special template within the EHR. Access to other parts of the EHR would be restricted through security controls. Enterprise content, collaboration, and communications management systems are not commonly used to support health care services, but can be helpful for business purposes. For example, when several individuals are contributing to the development of a document, enterprise content, collaboration, and communications management aids in version control and enables all parties to interact simultaneously as the document is being created.

In addition to different types of scanning software systems, there are image formats that result from the scanning process. The four most common are:

.PNG is suitable for text images or detailed drawings. There is no loss of image data when the image is scanned. PNG files can be very large, reducing the time it takes to retrieve them.

.JPG is a good choice for digital photos and other colorful images. This format compresses the size of these files, making them smaller and faster to access than PNG images, although there is a slight loss of image quality.

.TIF overcomes the loss of quality in the JPG file format while still compressing the size of the file. These images are also versatile because you are able to apply data tags, resulting in ECMS capability. However, these tags are not standardized so they are compatible only with the software that created the imageand not compatible with EHRs.

.PDF is probably the best choice for text documents. Some programs, such as Adobe Acrobat, use optical character recognition technology to scan text characters of the text. You can edit the text later and search for words or phrases in the document. Adobe Acrobat can also be used to create templates that can be filled in or to affix an electronic signature to the document. Since the PDF format includes automatic image compression, it is a satisfactory choice for scanning images.

The PDF file format is the most standardized, in that anyone with any computer can retrieve and use a PDF file with a (freely available) reader. However, this process does not incorporate the content of the PDF file into an EHR. To do so, the PDF file must be transported to the EHR (from the scanning software or other source of the PDF) as an attachment to an HL7 message. The transporting mechanism would provide information on how the PDF file should be indexed and where it should be filed, as well as how the PDF document is made known to the user.Finally, there are different types of scanners and other associated equipment: Flat-bed scanners scan one sheet of paper one at a time. They are not satisfactory for bulk scanning, but are useful for scanning objects such as insurance cards, drivers licenses, pages from a book, etc. Different sizes are available. If only small items are to be scanned, a small scanner can easily fit on a desk.

Sheet-feed scanners automatically scan multiple pages, one after the other. They are most suitable for bulk scanningalthough staples, sticky labels, and odd-size forms will not go through these scanners.). Different sizes are available. If you plan to scan records routinely, it would be appropriate to acquire a sheet-feed scanner that is heavy-duty enough to withstand a lot of scanning. However, if you plan to scan all archived records and then only scan occasional documents, it may be suitable to lease a large-scale sheet-feed scanner for the archived record scanning project and then buy a flat-bed scanner for occasional use.

Dual-monitor workstations often are used in large-scale scanning operations. The scanning equipment operator can view two scanned pages simultaneously, or view the indexing structure and a scanned image simultaneously.Selecting and Implementing EDMS

Selection Although some EHR systems incorporate EDMS functionality, many EHR vendors are moving away from proprietary EDMS offerings. Instead, they are recommending EDMS vendors with whom they have worked, to ensure compatibility. Even if your EHR vendor offers EDMS functionality, it is advisable to consider other options. If you will primarily be archiving records for occasional retrieval, you might consider using an EDMS contractor who can do the job faster and often for less cost than hiring and training your own staff and buying or even leasing your own equipment. However, if you anticipate scanning a fairly large amount of documents on a routine basis, you will probably need to acquire the necessary equipment and software, and determine whether existing staff, additional staff, or part-time staff can perform the scanning.

When searching for EDMS vendors online, be sure to set your browser to electronic document management systems in health care. Several other industries, such as education, are heavy users of EDMS. Vendors for these industries will not necessarily provide the same functionality you need.

Approach the selection of EDMS as you would section of your EHR. Issue a solicitation for a bid or proposal that describes your needs in detail (see Section 3.4 Soliciting Bids for EHR and HIE: RFI, RFB, RFP). If you already have an EHR, identify it so that vendors can determine compatibility. Describe the volume of documents you have to scan and their age. This is important for determining the nature of scanning technology, the amount of storage, and the level of indexing needed (older records will be less likely to be retrieved, so do not need as much indexing).

Make sure you are addressing backup storage. You may use a server to store all of the scanned images, but you should also have either another server at a remote location or, at minimum, backup CDs stored at a remote location. Rule of thumb: The contents of one four-drawer file cabinet will convert to one CD.

If you are soliciting bids from a contractor to perform the scanning for you, determine if scanning will occur onsite or offsite. If only offsite is offered, you will want to ensure that the company is fully bonded, and may even want to inspect or require that an inspection of the facilities to ensure security. You should specify whether you want the paper warehoused for an extended period of time, warehoused temporarily, or destroyed immediately. Because your scanned images are accepted in a court of law under the best evidence rule, you will most likely want to destroy them. However, you may preferor the state in which you operate may requirethat paper documents be warehoused for a few months, allowing you can identify any issues with documents that are missing or were not scanned properly. It is advisable to check with your attorney before you decide when to destroy the original paper records.

If you will be doing your own bulk scanning for archival records, two other considerations are important: Space to stage document preparation, scanning, and temporary storage of records scanned. Some organizations find they do not have adequate space to perform these functions and need to rent temporary space.

Paper destruction services. You may already use a shredding company to shred confidential documents. These companies typically supply locked bins in documents are temporarily held until the bins are full. Then the service comes and puts the bins into a truck outfitted with a shredder to conduct the shredding at your site. For a large-scale scanning operation, you may need a locked storage area, rather than simply bins, to hold the records to be shredded. You should also obtain a manifest of destruction each time a batch of records is shredded.ImplementationIt is of utmost importance to ensure that each document has been scanned and indexed properly. Not only is this necessary because you will be destroying the paper documents, but your users will not tolerate poorly scanned documents, may have difficulty finding documents. Many users stop referring to scanned documents entirely if the process is too time-consuming. Unless you use ECMS, which recognizes the name and/or identification number of a persons documents, there will be no way to find a misfiled document except to open and review every document that has been scanneda virtually impossible task.

The following are steps to be taken to implement EDMS:1.If bulk scanning will be performed, ensure space is acquired for staging and temporary storage. To determine the duration of your space needs, estimate the volume of documents to be scanned and the time it will take to prepare, scan, and index them

2.Install and test hardware and software. Ideally, find some typical documents to scan in order to test whether each type of potential issue can be addressed by the equipment, following your policies and procedures.

3.Develop policies and procedures for initial scanning:a. Document preparation. In this step each document is examined to determine that the individuals name is on the front and back (if the back is written on), that identification information is correct. Remove staples, repair torn or dog-eared pages, photocopy any documents on card stock that will not go through a sheet-feed scanner, arrange documents in date order by type of document, and ensure all pages are in the proper orientation. If any documents are of poor quality, photocopying them while adjusting the copy contrast (light and dark) may improve legibility. If not, write or stamp on the document Poor Quality Original (PQO) and place it in its proper location for scanning.

b. Document scanning. This step requires daily review of the scanner itself to make sure it is calibrated for proper image quality. Once ready, a stack of approximately the appropriate number of documents should be fanned and inserted into the scanner. Once each batch is scanned, the documents should be compared with the scanned images to make all are included. Check to make sure that both sides of two-sided documents are included and that the sides are in the proper order. Make sure all documents are properly oriented. If a document is PQO, attempt to improve the readability by rescanning with different sensitivity settings.

c. Second quality control. Ideally, a different person should perform the same quality control steps as described above a second time.

d. Indexing. If indexing is a manual process, each document image must be reviewed to determine if all the information is correct and that the documents belong together. The documents are then moved to their appropriate folder or a new folder is created. If the indexing process is automated via barcodes or optical character recognition, verify that each document is placed in the correct folder. It is helpful to compare the scanner count with the indexing count and reconcile each batch before moving on to another batch.

e. Third review and quality control. It strongly recommended that a third quality control step be performed to ensure that the records in each batch have been scanned and indexed correctly. Some facilities establish a randomization process to sample records for this final review. If more than the specified threshold of errors exists, another sample is taken. This moves to review of the entire batch if necessary.4.Develop policies and procedures for ongoing management of scanned documents:a. If a document is found that needs to be inserted into an already scanned set of documents or record, this may be done by scanning the document and manually indexing.

b. If there is a problem with an image and the document can be rescanned from temporary storage, do so and replace the defective document with the new document.

c. If there is an addendum, correction, or signature that needs to be added to an existing document that has been scanned and the original is no longer available, establish policy that reflects how this is handled in the paper record.i. For an addendum to be referenced from an existing document to a new document, the procedure in a. above is followed for the new document and the procedure in c. ii below is followed for the markup of the existing document.

ii. To make a correction, print out a copy of the scanned image and line out the error with a single thin line, indicating error. Date and sign the correction, then rescan as above in step a. Delete the original scanned image. If there is an annotation to be added to a document (such as additional information or reference to an addendum), print out a copy of the scanned image and add the annotation on a separate image to follow, dating and signing it with the current date and the person making the annotation.

iii. Signatures may be added in one of two ways. A signature can be added as described in c. ii above. Or, it can be added within software that follows an electronic signature process. This process designates that a review of a document and intent to sign the document have been performed by an individual authorized to do so (having applied unique user identification and password, or other form of secure authentication process, in order to retrieve and review the document). 5.Develop policies and procedures associated with productivity standards if performing bulk scanning operations or large-scale scanning on an ongoing basis.

6.Train staff members on the policies and procedures you have created. Training should include actual scanning under supervision until the person is confident and the supervisor has observed that all appropriate steps are followed. Monitoring of productivity and quality control should be stepped up during the training phase.

7.Bulk scanning is a very tedious process. Breaks are needed to avoid repetitive motion issues and to refresh. It is recommended that not more than 50 minutes of every hour be spent scanning, with 10 minutes of break time for the person to exercise, use distance vision, or simply relax.

8.Post-implementation steps should include conducting quality control and encouraging everyone who retrieves scanned documents to report any issues in image quality or indexing. Address these by correcting the specific problem, looking for root cause, and taking broader corrective action if necessary. For additional information, see:

Document Management and Imaging Toolkit, American Health Information Management Association, 2012, available at: http://journal.ahima.org/2012/12/07/document-management-imaging-processes-toolkit-supports-ehr-implementation/

Automated Systems for Child Support Enforcement: A Guide for Electronic Document Management, 2007. (Although geared toward social services, this is an excellent resource for all type of health care providers.) Available at: http://www.acf.hhs.gov/sites/default/files/ocse/dcl_07_36a.pdf

Fundamentals of the Legal Health Record and Designated Record Set, American Health Information Management Association, 2011, available at: http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_048604.hcsp?dDocName=bok1_048604Copyright 2013

Updated 11-20-13 PAGE Section 6 OptimizeOptimization Strategies for Electronic Document Management Systems - 1