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Tips for smoothing the rough edges in your hybrid paper-digital EHR workflow

Bar codes are key to enabling digital EHR workflows to assimilate lingering paper forms, reports and other scraps floating around the hospital environment.

Chances are, if you're managing a hospital's EHR workflow, someone still needs paper, and it's a hassle moving data from paper into the EHR. Maybe someone is using intake forms for inpatients, or signed consents for same-day surgery patients. Or perhaps -- as in the case of Tri-City Medical Center, a 400-bed hospital in Oceanside, Calif. -- specialists at remote clinics don't yet have interoperable software with an onramp into your EHR, so they write patient notes and reports in Microsoft Word, print them and hand them off to HIM staff.

That's the reality of health IT's present evolution: There's no single EHR system that can make a complex hospital workflow completely paperless. If there is, there's no one hospital implementation or site that can take perfect advantage of all the features enabling paperless workflows. Or, as is the case at many facilities, practitioners use systems from multiple EHR vendors, which complicates things even more. The end result? There's paper still floating around the system, somewhere.

Scanning that paper is how it gets into the EHR so that physicians and nurses can access it digitally -- and how the organization attests for meaningful use and reaps CMS incentives. Terri Hartzell, Tri-City's medical records operations manager, said that assigning bar codes to every paper page prior to scanning it into the EHR system is the key to maximizing efficiencies -- as well as maintaining accuracy -- in a hybrid paper-digital workflow most hospitals must use.

"If you do it right, that bar code does all the thinking for you," Hartzell told after presenting the American Health Information Managers Association 83rd Convention and Exhibit. Meaning, upon scanning a page with a bar code, the bar code instructs the EHR to attach it to a particular patient record, and determines where to "file" it within the network's storage hierarchy. "You just don't have the errors."

Hartzell and co-presenter Connie Renda, CEO of Integrity Health Information Services, a medical records scanning service, converted Tri-City from an all-paper workflow to an all-digital workflow in which paper documents are scanned on to the network and eventually recycled, not stored. They presented some best practices based on their experience:

  • Get IT leadership and HIM managers working together.  Records management understands workflow; IT understands technology. Meshing the two groups together at the start of a document-scanning implementation will build the best mousetrap. IT will be tasked with jobs such as evaluating bar code standards (yes, there are several) and scan-to-EHR applications compatible with your EHR. IT managers will also have to think about making room in data center storage, building conduits within the EHR to take in and view scanned documents, as well as implementing the optical character recognition (OCR) engine that makes scanned text searchable and editable on screen. HIM managers will know who's still using paper, why, and in what order it makes sense to convert to the scanning, department by department. 
  • Plan two years in advance. It might seem like overkill, but getting equipment and space for document scanning, setting up and testing bar code systems, training former file clerks to be document scanners and answering other questions (i.e. which paper records need to be stored off-site for compliance purposes, and how to manage HIPAA compliance for restricted paper forms such as behavioral health or substance abuse-related patient documentation) takes a lot of time and effort. Don't forget the meetings with nurses, physicians, specialists and compliance staff to answer all the EHR workflow questions you'll be asked en route to your well-conceived scanning initiative.
  • Scanning every single archived record is not cost-effective. While some hospitals have chosen to digitize all records going back a certain number of years, both Renda and Hartzell said that it's not cost-effective -- you end up looking at so few archived records in the long run, it's actually cheaper to pay an off-site paper records storage company (Tri-City uses Iron Mountain) to hold and retrieve records on an as-needed basis and then destroy them when compliance rules say it's time.
  • Keep the paper copies of scanned documents around a little while before recycling them. Do this, Hartzell said, to resolve errors that invariably will occur in the document scanning process. Her facility keeps the paper copies for six months, because that's what she's comfortable with; she knows of other health care providers that use shorter intervals (three months, one month, even two weeks).
  • Set productivity benchmarks for document scanning staff. This is a new job that puts experienced employees at the tiller of new equipment and software. Some will succeed, some will do well after extra training, and some will fail. Set expectations of how many pages or patient charts per hour they should be scanning -- IT staff can set up software that tracks and audits productivity. That way you'll know how to set realistic goals, and iron out employee productivity issues with remedial training or job reassignment.
  • Get help. Hartzell contracted Renda's firm to employ experienced medical document scanners while her own staffers were being trained and getting the hang of their new EHR workflow. Renda said that when her team's called in after a go-live date to supplement a scanning implementation, the hospital usually needs them for months -- because it's hard to stay caught up when you're scanning documents for yesterday's patients in addition to today's admissions and tomorrow's scheduled appointments.
If you do it right, that bar code does all the thinking for you. You just don't have the errors.

Terri Hartzell, medical records operations manager, Tri-City Medical Center

"[We believe] it's beneficial to have part of the documentation outsourced during the first couple of months, during that crucial period after the go-live for document imaging," Renda said. "[We] were able to assist Terri and her staff not only with familiarizing them with the process, but also training them so they could be on their own."

Hartzell concurred with that opinion, saying that having outside experts come in and demonstrate their techniques taught her staff many lessons they would have had to learn the hard way. One such lesson: Removing staples entirely -- instead of just separating stapled documents into their component pages and leaving the staple in -- prevents the slow destruction of the scanner's glass bed over time. Staples put scratches in the glass, which not only affect the ability of the scanner to "see" documents, but they also can affect accuracy of scanning before the scanner eventually goes "blind."

Let us know what you think about the story; email Don Fluckinger, Features Writer.

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