And while many of UPMC's hospitals are highly automated (seven are at HIMSS Analytics Stage 6; one is at Stage 7, the highest rank), UPMC must contend with an array of information residing on paper. Those documents must be scanned by the HIM staff and then linked to the core EHR. "We scan about 2 million pages a month," says Nancy Soso, executive director of HIM. "It's an enormous orchestration task."
Compared with most hospitals, UPMC is highly sophisticated in its use of information technology. But its complex document management operation reflects a greater industry challenge-coping with a staggering amount of information needed to inform patient care and facilitate the billing thereof. Many of these documents-think EOBs, advance directives, and referral requests-originate outside the walls of a hospital. But even within those confines reside numerous forms and records beyond the reach of advanced EHRs.
To manage all this information, hospitals and group practices rely on document imaging and management systems. In their most rudimentary form, the systems have provided electronic snapshots of the documents that once lived in a paper folder. Beyond that, current-generation document management systems have more advanced features that can automate routing of scanned documents and work in conjunction with medical devices to capture patient data directly.
Here's the rub: Preoccupied with EHR deployments, many health care organizations however have not moved beyond the technology's scan-and-store capability. Enhanced efficiency rewards those that do. Tech-savvy health systems have devised ways to adjoin their document management systems with other technologies, such as bar coding and optical character recognition, to make their systems more valuable.
Keeps on Coming
UPMC constitutes a case study in the bevy of documents associated with running a modern hospital. Its core EHR, from Cerner, is in varying stages of deployment at its member hospitals. And the Cerner system is a treasure trove of clinical documentation. As Julie Brown, director of HIM, explains, the Cerner system enables order entry, handles nursing and physician documentation, and also receives lab, radiology, and pathology data directly from ancillary systems via interface. The data feeds, combined with native Cerner data, constitute a "comprehensive inpatient EHR," says Brown.
Yet, many documents and forms must still be scanned and stored outside Cerner, adds Soso. This list includes records still maintained on paper forms in hospitals not fully deployed on Cerner's multiple modules. For example, some physicians make handwritten notes, she says. Other documents, such as patient consent forms, patient instructions, advance directives, power of attorney, and records from referring physicians-such as pre-operative notes or labs-must also be scanned. "There is a constant influx of deliveries of paper from the hospitals," Soso says. "Our imaging operations are responsible for receiving, preparing, scanning, indexing and doing quality checks on all the documents." The process, Brown adds, is labor intensive. "We have to make sure all the documents are prepped, any staples removed, and any holes taped. We make sure the documents won't get stuck in the scanner. And the documents are organized in a certain way."
UPMC's scanning system, from McKesson, has been working in conjunction with the Cerner EHR since 2006. The Cerner and McKesson documents live in parallel universes, requiring staff to toggle back and forth. Accessing data is simplified somewhat by a single sign-on system that UPMC has embedded in its infrastructure. The single sign-on system, from Sentillion, links the Cerner and McKesson systems to the same patient, so as staff move between the two they're automatically directed to the same patient, rather than having to search independently. In the year ahead, UPMC will integrate viewing of scanned files directly into Cerner. "McKesson will still be the backbone of document imaging, but the images will pop up in Cerner," Brown says.
Some of UPMC's affiliate hospitals had been doing document imaging prior to the Cerner deployment, while others relied on paper charts. A few have gone live with Cerner and McKesson simultaneously, but the sequencing and penetration of Cerner modules varies widely. And the less Cerner modules deployed, the more paper forms there are to scan. Currently scanning is done post-discharge. "With 20-plus hospitals, no two roll-outs are identical," Soso says.
Other health systems run EHRs with tightly integrated document management systems. Cleveland Clinic, for example, has been running an Epic EHR since 2000, beginning on the ambulatory side of the organization and later expanding to the inpatient. The Epic system is supplemented by a document management system from Hyland, called Onbase. Documents originating in Onbase are viewed directly through the Epic EHR. "Document management is not our core technology, but Onbase augments what Epic can't do," says Dan Slates, director of integrated enterprise applications.
Spanning 10 hospitals (with nine in Ohio and one in Florida), Cleveland Clinic has gradually expanded its use of both the EHR and the document management system. On the inpatient side, the EHR is still being rolled out to a handful of member hospitals. Once deployed, Epic serves as the central repository of records, as scanned images are presented through it, Slates explains. "The document management system is for documents with no traditional pipeline into the EHR," he says. These include EKG image files, which are routed via interface from their parent medical device as PDFs into the document imaging system. "Loading image files from the EKGs was a big win for us," Slates says. "It went beyond the traditional scan of a piece of paper."
Cleveland Clinic still does plenty of traditional scanning however. Its member hospitals have universally adopted scanning of driver's licenses, insurance cards, patient registration forms, and patient consent forms for several years. And for Cleveland Clinic's community hospitals not fully deployed on the Epic system, the scanning system is used to capture some clinical forms that will be eventually replaced by the EHR. "There's a lot of paper in the community," Slates says.