The centralized health information management department at the University of Pittsburgh Medical Center is a very busy place-as in 24/7/365 busy. There, some 75 staff members are devoted to one primary function-keeping the patient records from UPMC's 20-hospital empire up to date.

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.

Supplemental System

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.

Document management systems can be a boost at the group practice level as well. Pulmonary and Sleep Associates, an 11-physician group practice in Boca Raton, Fla., uses a document scanning module in its EHR to trap charts that once were kept on paper, says Susan Ruby, administrator. The practice installed a hybrid EHR/practice management system, from Aprima, in late 2010. At that point, it began scanning in old charts as patients came into the practice.

Now, nearly two years into the deployment, the practice has retired its paper charts., Ruby says. It also can electronically import into the Aprima system documents faxed to it from referring physicians.

With its ability to accept image files directly from a fax server, the document management component lets the practice cope with less sophisticated data trading partners. For example, the practice's EHR has the capability to accept lab results electronically. But its lab partner lacks the ability to send results in a direct digital feed of data, so those results are scanned from the fax server in as well. "We don't have any more paper," says Ruby. "The scanning system is like an employee-without benefits."

The Dream of Paperless

The repository function of document imaging systems is well established in the health care industry, says Jeff White, a principal at Aspen, a Denver-based I.T. consultancy. Vendors like Epic have done a good job of embedding scanning tools directly into their software, he adds. In Epic's case, the EHR has a built-in scanning module suitable for small jobs, such as scanning driver's licenses at the point of care. And for larger-scale jobs, Epic offers the Hyland software as an adjunct. Those options appeal to health systems attempting to move to EHRs, he says. "When organizations are moving to EHRs, they want to go as paperless as possible," White says. "But they still have paper to process, such as documents from outside the organization."

Health care organizations may be missing the boat with document imaging and management systems, however. White points out that more sophisticated systems focus as much on the management part of the equation as the imaging. Vendors like Hyland and EMC offer systems with more advanced capability that can enable better management of workflows around routing forms. "Many processes in health care are paper-based and that is where organizations can benefit a lot from document management systems," he says.

White points to capital purchasing and approvals as one area where documents often circulate among a variety of decision-makers, each granting levels of approval or making modifications. A robust document management system could handle that chore, he says, by routing electronic copies of the forms and enabling electronic signatures along the way. "You can avoid shuffling paper around," he says.

Document management systems also can enable organizations to keep track of versions of documents as they change, adds consultant Deborah Kohn, principal at Dak Systems Consulting. But "version control" is a feature rarely used in the industry, she contends. Version control could, for example, enable an organization to track changes made in dictated physician notes, as they wend their way from the original taping, to the transcriptionist, and back to the physician for approval. In many EHRs, only the most recent version of a dictated note can be viewed, with earlier versions pushed aside-and sometimes deleted.

Kohn says that EHRs by themselves often lack version control, making it hard to access historic versions of the chart. And when it comes to producing documents, EHRs struggle, she says. "It is easy to put data into an EHR, but hard to get it out as a document," she says. "We need discrete structured data, but we also need to deal with documents."

Bar Coding Plays a Role

To get more bang for the buck, some health systems have incorporated a variety of auxiliary technologies into their scanning workflows. UPMC, for example, has developed a homegrown bar coding system which works in conjunction with its McKesson document management system. The bar code system was part of an enterprise forms standardization effort, says Brown, the HIM director. Rather than supplying hospitals with paper forms, UPMC has a "print on demand" set-up in which forms as printed as needed. "That way we can tightly control the forms from the inventory and design perspective," she says. "We also have downtime forms in case EHR goes offline."

Clinicians needing a form generate one from a local workstation. They enter patient identifying information and the specific encounter the form relates to. The form generating system then looks the patient up in Cerner, and affixes a bar code on the predesigned form, on which clinicians write. Forms available include progress notes or history and physicals, Brown adds. "The majority of forms are bar coded," she says. "With some state forms, or forms from outside UPMC, we can't bar code automatically, but provide bar code labels to affix manually."

The bar codes are embedded with relevant patient information that is digested by the McKesson scanning system. Thus, documents are routed to the correct document folder in McKesson. The system also knows if a form is single- or double-sided, and can alert staff if a page appears to be missing after being processed.

Forms control, says Brown, is a major component of maintaining quality document management. Under its current set-up, the HIM department can alter the design or data fields of any given form from a central location. That way, any subsequent forms printed out through the system would be up to date. It's more efficient than supplying multiple hospitals with pre-printed stacks of forms, she says.

Cleveland Clinic is also taking its document management system to the next level. It is in the early stages of deploying electronic signature pads to trap patient consents, says Slates, the director of integrated enterprise applications. Currently, member hospitals scan in consent forms after they're signed. "Patients sit down with registrars, we print out a packet, they sign it, and we scan back it into the system," he says. "You are printing something only to have someone sign it and scan it back in." With electronic signature pads, the patient would read an electronic form on a handheld device, then sign it. "It is much more efficient," Slates says.

A pilot for the electronic signatures-which would be captured in the Onbase software-has been underway for six months, he says. Cleveland Clinic is also exploring other options to capture consents electronically. In another pilot, it's capturing informed consents for surgery using the scanning component indigenous to Epic. And it's also exploring other vendors which specialize in forms capture, Slates says. Slates hopes that Cleveland Clinic will ultimately settle on one method to capture patient signatures. "It would be easier to build and support, but the reality is that we are big-nothing is rolled out to 10 hospitals at a fast clip," he says. "We will probably migrate to one technology, but in the near term we will have several technologies competing to determine what is the best solution."

Beyond its electronic signatures projects, Cleveland Clinic is also incorporating advanced optical character recognition into its Hyland system.

The goal, says Slates, is to "allow straight throughput processing of forms with no human indexing." For the past year, the clinic has been using OCR capabilities for bills and payment requisitions being handled by its accounts payable department.

In essence, a bill comes through, is scanned, and the system can recognize the kind of bill, the vendor, and relay that information to Cleveland Clinic's financial management system, from Lawson.

Streamlined Workflow

The workflow entails several software packages working together. First, the requisition is scanned into the Hyland Onbase system. Then the data is read by software from a firm called Brainware, which is integrated with the Hyland set-up. Brainware provides advanced OCR capability, parsing the data out into relevant fields in discrete readable bundles, sending that information back to Hyland, which in turn feeds it to the Lawson system. "It sounds convoluted, but it happens behind the scenes," Slates says.

The set-up has streamlined a tedious process, Slates says. In the old set-up, staff would scan a bill, then on another screen manually enter data into the Lawson system. Now half the bills can go through straight to Lawson without human intervention. "We want to ratchet up the number," Slates says. "The system's not yet smart enough to get 100 percent routed automatically, but we've cut the workload in half."

Workflow automation built around document management technology is the next big area of growth in the industry, predicts White, the consultant. "Due to meaningful use requirements, the priority in capital investments is to improve clinical processes, at the point of care," he says. "Once organizations have gotten beyond their huge investments in EHRs, they will be ready to invest in document management systems" that transcend scan and store capabilities.

The data exchange requirements of meaningful use will also drive increased use of document management systems, says Neil Simon, chief operating officer of Aprima, the EHR/practice management system vendor. Meaningful use calls for a certain amount of discrete, structured data that is beyond the reach of a scanning system, he points out.

In support of data exchange, it also calls for the ability to send data summaries via a Continuity of Care Document, an XML-markup standard which specifies how to exchange certain patient information.

"A lot of data is not always structured, so you will always see a lot of unstructured data, PDFs or free text," Simon says. Those documents will be wrapped in the CCD." Document management technology will enable the transmission of those bundled packets, he says, noting that the industry has a long way to go to electronic data interchange.

"Even though we talk about the electronic world, a lot of health care is still done via the fax."

Switching Gears on Document Management

St. Anthony's Memorial Hospital, a 146-bed community facility in Effingham, Ill., is about to upend its document management traditions. For the last five years, the hospital has used an EHR from Meditech, which handles patient registration, billing, physician orders, results reporting and clinician documentation, says Teri Phillips, manager of health information. But its final repository for clinical records has been provided by 3M, whose document management system receives ongoing data feeds from Meditech. "Everything we documented in Meditech would come to 3M," Phillips says. That meant that physicians would create orders in Meditech, but later sign and complete charts in 3M.

Now St. Anthony's is on track to establish Meditech as its legal, final record. Rather than export data to 3M, the data will reside in Meditech. And other documents not generated in Meditech would be scanned via Meditech's built-in document imaging module, Phillips says. The move was precipitated by the growing expansion of the Meditech system into such as areas as physician progress notes, she says. "As we create more in Meditech, it makes sense to keep it as the legal record."

St. Anthony's will continue to use a variety of other 3M products, including dictation and transcription, and coding and abstracting functions. The new set-up also eliminates a challenging interface between Meditech and 3M, Phillips says. It proved difficult to make sure that all chart updates in Meditech were transmitted in a timely basis to 3M's chart viewing module. "We had to make sure the edits matched," Phillips says, referencing such chart modifications as corrected discharge status or late nursing entries. Now, any updates in Meditech will simply be stored there, eliminating the need for dual storage. Physicians too will have one stop shopping for any clinical data entry and subsequent chart completion.

As part of the transition, St. Anthony's will convert all of the data in 3M and load it in Meditech. That includes five years' worth of archived Meditech charts and any other documents scanned separately into 3M. Its scanning tool has been in use since 2005. "The goal is stop paper use and do everything online," Phillips says.

Coping with a RAC Audit

As RAC coordinator for Mobile, Ala.-based Providence Hospital, Toshi Leys faces a daunting document management challenge. Since late 2009, the 349-bed hospital has been subjected to a series of audits under Medicare's recovery audit contractor program-designed to spot inappropriate billing after the fact. And the RAC program is just one of several audit programs underway.

The size of a RAC audit request can vary, but typically encompasses about 100-plus patient charts, experts say. Regardless of the number of charts in question, Providence must send the entire chart, which Leys says ranges from 90 pages for a short stay to as many as 500 pages for a longer visit. "We send the whole record," she says.

Compliance with the audit was time consuming. First, Leys had to create a spreadsheet to accompany all the charts sent to the auditor. Serving as a type of table of contents for the requested charts, the spreadsheet itself had 12 data elements. Leys then had to create a PDF-with a specific naming convention-for each chart. She did that, chart by chart, by accessing records housed in the hospital's document repository, from Siemens, itself a storehouse of both scanned and electronically interfaced documents. In turn, the PDFs were stored on a CD, encrypted, and sent to the auditor via FedEx. A week or so later, Leys would log onto a Web site maintained by the auditor to see if her documents arrived. Compiling all the records for a single audit might take three weeks, she says. "The process is tedious."

That's one reason Providence decided to outsource its RAC requests to an outside vendor, HealthPort. Now, the charts are still sent on PDFs, but the process is highly automated. When an audit request comes in, Leys enters the patient account number into the HealthPort system, which then searches the Soarian database and then imports the remittance advice for that patient directly into the HealthPort system. That triggers an alert, telling the HealthPort staff the file is ready to prepare. A HealthPort staff person pulls information from Siemens, by using a print option which creates an image file of the chart. Those files can be manipulated and re-arranged. When the file is complete, Leys enters the system and does a quality check. If everything looks fine, the file is dispatched directly (in a batch with other patient charts) to the auditor. Within two days, Leys can view the auditor portal to check on the status of the electronic transmission.

Later, if the auditor calls, Leys or a coding manager can pull up a copy of the chart in question through the HealthPort system. "We are looking at the same document together," Leys says. In case the hospital wants to appeal an unfavorable audit, it can use the HealthPort system to dispatch the needed files to yet another company it retains to do medical necessity appeals. And lately, appeals are on the rise, Leys says. "It is pretty much inevitable that if you have short stays, most of those will be denied on audit, even though they were medically necessary."

This story originally appeared in the July issue of Health Data Management magazine.

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