When it comes to document management and imaging systems, I.T. consultant Deborah Kohn is a straight-talker. The veteran systems implementation advisor has little patience for vendors that over-sell their document imaging and management systems. "Document imaging in not an EHR-some vendors say they are and shame on them!" proclaims Kohn, whose shop, Dak Systems Consulting, is based in San Mateo, Calif.

But in the next breath, Kohn emphasizes a point that many in the industry are still in denial about: While scanning documents and making them available as electronic images may not fulfill the holy grail of the EHR-namely digital, discrete data-the practice is not likely to disappear anytime soon. And in fact, the advent of the EHR may spur even more need for document management systems. "It is about time CIOs learn that discrete data is not the only thing they will be collecting, exchanging, and reporting. There are many uses for document managements systems-they won't go away."

Indeed, document management systems serve a variety of functions in the industry. For many organizations, they are a transitional bridge to an EHR. And even for organizations with a "full" EHR, they serve as a data archive of paper documents generated outside the hospital. Some providers have found utility in deploying document management systems in highly specialized ways in departments whose needs might not be met by any conventional EHR or practice management system. Finally, organizations with more advanced document systems use them to enable certain transactional functions, such as electronic signatures for incomplete charts, or as part of messaging systems for clinicians.

Despite its value, document management technology has decided limitations, and even its champions envision a day when its value will be marginal. A scanned file of a progress note may be "electronic," but its contents are usually not searchable in any meaningful way, nor do files in document management systems lend themselves to quality analytics or reporting-two of the cornerstones of pay-for-performance and quality initiatives from federal and commercial payers. Sophisticated document imaging systems work in close tandem with an EHR, but many systems do not-a limitation often cited in discussions of the two technologies.

Long-term contract

The sheer volume of documents in play in the health care setting-many of which are beyond the reach of even the most functional EHRs-suggest longevity for document management vendors. In 2009, 246-bed St. Anthony's Memorial Hospital, Effingham, Ill., scanned nearly 600,000 documents totaling over 1.1 million pages, attests Terri Phillips, manager, health information. For large health systems, the issue compounds. Across its nine hospitals in the Kansas City area, St. Luke's Health System scans some 19.5 million pages annually, says Sharon Korzdorfer, director of health information management.

Both organizations have EHR initiatives underway. And they underscore a key trend in the industry: the pathway to digital data is a long one, and a document management system can provide relief from paper documents along the way.

St. Anthony's, for example, implemented a document management system, from St. Paul, Minn.-based 3M Corp., in 2005 with the goal of providing clinicians an easily accessible version of its paper-based, post-discharge inpatient record. Two years after it introduced the document management system, St. Anthony's deployed a new clinical information system, from Meditech.

However, the hospital still wanted to maintain the convenience of the centralized record offered by the 3M set-up. "We knew it would be a long transition period to getting a fully functional EHR," says Phillips. "We still have handwritten documents and other documents, like EKG printouts, that are not interfaced anywhere, and are now being printed and scanned. We wanted the physician to see the medical record from anywhere, and now they can see the entire historical record." St. Anthony's document imaging system now serves as its "legal EHR."

Lowering expectations

Some health systems eyeing enterprise EHRs recognize that the health care ecosystem still relies heavily on paper, and therefore lower their expectations from the get-go about the amount of data they will be able to create, capture and store digitally.

Consider St. Louis-based SSM Health Care, a 16-hospital system that is partway through a massive deployment of an EHR, from Epic Systems, Verona, Wis., that began in 2008. The goal is a standardized clinical record across the enterprise. Through June, SSM had completed the deployment at nine hospitals, and was on target to complete the effort, "Project Beacon," in 2014. It is rolling out the new EHR hospital by hospital-while at the same time implementing a document management system from Westlake, Ohio-based Hyland Software, designed to work in tandem with the Epic system. "It is a complete cultural change," says Lilley Hammock, clinical transformation manager.

Prior to Project Beacon, SSM maintained a hybrid chart, using a legacy McKesson system for patient registration and certain financial applications, paper for most clinical documentation, and a few best-of-breed systems scattered in ancillary departments, such as anesthesia. Eventually, SSM will replace the legacy McKesson systems with an integrated clinical/financial suite from Epic, but it has opted to put in the clinical side first. It will scan documents from its old financial system, making them available to users at a hospital deploying the new clinical system. Likewise, it will scan any documentation from its anesthesia system until it gets replaced by its modern Epic counterpart.

Training on the various systems has been the big challenge, says Amanda Blase, team leader, health information management. "We are training on Epic and also on Hyland," she says. "Meanwhile, employees are required to keep working in the paper system they were used to. Time management is the issue." The Epic software is closely integrated with the Hyland scanning module, which makes it easier to adjust to a new workflow, adds Hammock.

Transitional bridge

In addition to serving as a transitional bridge to the EHR, a document management system can provide a type of electronic storage cabinet for the multitude of documents generated outside the walls of a provider organization, but which nevertheless support important clinical decision-making. Zangmeister Center, a 16-physician hematology/oncology practice in Columbus, Ohio, introduced a specialty EHR, from Varian Medical Systems, over a decade ago.

As a result, the lion's share of its internal clinical data is electronic. Yet, the practice must cope with a universal issue in health care: There are a multitude of forms and other documents that either originate as paper, such as patient consents, or defy an easy interface to its EHR, such as graphical flowsheets generated by patient monitors.

Using technology from Madison, Ala.-based CabinetNG, the practice scans and indexes up to 500 pages a day, says Andrew Cooper, information technology manager. Documents are cross-linked by the patient's billing number, and physician EHR users can access the database of document images by clicking through to the CabinetNG "retriever application" that runs in tandem with the EHR.

At Zangmeister, scanned documents include pathology reports, records and requests from other physicians, and some reports required by Medicare. In addition, Ohio law requires that the practice maintain pharmacy dispensing reports-attestations that any medication dispensed was what the physician ordered. "It's a piece of paper that has to be linked to the patient," Cooper says.

Flu season influx

In the complex world of health care documentation, there's still plenty of information that evades electronic capture. That's why some organizations use document management systems to fulfill limited, but important, purposes, oftentimes in niche areas of care. Aurora Healthcare, an integrated delivery system based in Milwaukee, runs a large flu immunization program, inoculating nearly 100,000 citizens across southeast Wisconsin during the final quarter of each year. The labor-intensive program is administered through Aurora's visiting nurse association, says JoAnn Smith, billing manager for the department. Even though the immunizations were issued during a three-month period, "it seemed like we were working on the flu program for an entire year," says Smith. That's because patient immunization consent and encounter documents had to be keyed into two different reporting systems, one for the state immunization registry, another for services reimbursable by either Medicare or Medicaid. "Half the patients were on Medicare/Medicaid, but everyone needed to be entered into the state registry," says Smith.

Last year, in an effort to streamline the task, Aurora implemented a document imaging system from Boulder, Colo.-based Parascript, which is designed to scan standardized forms and disseminate the data into individual data fields. Smith heard about the system from her husband, whose employer, FedEx, uses the technology. Aurora purchased the system for about $30,000, which includes a dedicated server, the software and user licenses. Within the first year, the health system had a positive return, saving $50,000 in reduced labor costs and overtime. Rather than individually keying in the patient consent forms, Smith's staff now feeds them through a scanner, which converts the handwriting into a typed digital field. Aurora then uploads the files, which are transmitted to a billing system for the Medicare/Medicaid patients, and a feed going straight to the state registry.

The main glitch in using the technology, Smith recalls, was the poorly designed form that Aurora scanned. "We used our original forms, which were not set up the best to scan," she says. "About 15 percent of the documents were not readable, so we have modified the form." The new forms, which go into circulation this year, should provide a cleaner scan the first time through, Smith says. The forms will have bigger boxes and be a consistent color-the staff had used forms of different colors to denote different patient categories. "The salmon color paper we were using did not scan well at all," Smith says.

Sophisticated document management systems can do more than serve as repositories of scanned documents. A few hospitals are using the technology to supplement their EHRs, enabling physicians to complete their charts by signing scanned charts electronically.

As part of its Project Beacon, SSM Health Care grants physicians access to its document management repository through its Epic EHR. If health information management staff notice unsigned physician documentation, they can place a deficiency note on the chart, alerting the physician electronically. The physician can then sign the charts electronically by opening up the document in Epic and clicking a button that appends a date and time stamp to the file.

Chart completion

St. Anthony's Memorial Hospital has a similar process. There, physicians can complete charts online, signing them in the 3M document management system. Currently, physicians cannot access the 3M system through the hospital's EHR, from Westwood, Mass.-based Meditech, but the hospital is in the process of building a link from one system to the other. The Meditech system automatically feeds its clinical reports directly to the content management system, which serves as the legal record. Coders and billers work in both systems, toggling back and forth.

Billing is performed through the Meditech system, while insurance cards and consent forms are maintained in the document imaging repository, all linked by a common account number. Phillips, the manager of health information, says coder productivity has increased by 25 percent since the organization began scanning documents five years ago because coders no longer have to handle and manage paper records. In addition, St. Anthony's ended its contract with an outsourced release-of-information firm, adding over $60,000 in extra revenue, Phillips says. "We can quickly print requested copies of records, invoice, and keep the revenue, rather than having to contract with a service," she says.

System limitations

Despite their utility, document imaging and management systems have limitations. Some CIOs see the technology through a jaundiced eye as a result. Lior Blik, acting CIO at Hoboken (N.J.) University Medical Center, describes document imaging systems as being of limited use. Merely scanning in paper records, while saving storage costs, does not address the fundamental problem of poor physician handwriting, contends Blik, who also serves as CEO of NIThealth, a New York-based consulting firm.

By way of example, the interim CIO describes scanning as a protracted, labor-intensive enterprise that does little to support care while the patient is in the hospital. Blik is managing the implementation of an EHR at University Medical Center, and says that document management technology will be used sparingly, "except for back-office files." Even document management systems that are tightly integrated with EHRs raise issues of screen design and naming nomenclatures.

Limitations aside, many organizations that have implemented document imaging systems are looking for ways to expand the use of the technology. Zangmeister Center, the group practice, is looking to store its clinical trials compendiums in its imaging system. "Instead of keeping multiple copies of a six-inch binder, we will store it and share it electronically," says Cooper, the I.T. manager. "We are also adding HR and other administrative documents into the system."

Likewise, SSM Health Care is looking to create a repository of financial documents in its imaging system. "We will include anything signed by the patient or anything we receive from the payer, including summary data," says Hammock, the clinical transformation manager.

This article can also be found at HealthDataManagement.com.

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