Friday, May 14, 2010

Document Management in Healthcare

What is Document Management?

For a variety of definitions from the Web, click here.

I like examples to illustrate definitions so here's mine from heatlhcare.

Most doctor's offices have a room in which they store patient folders, often referred to as charts.  In these folders are stored the paper that describes the care provided to the patient and typically includes

  • physician notes that detail how the patient presented, what was discussed, symptoms that the physician assessed, the diagnosis the physician arrived at, and the treatment / prescriptions ordered to address the symptoms
  • medical laboratory results from tests perfomed due to physician orders
  • prescriptions ordered
  • medical histories, often completed jointly by the patient and a nurse or the physician
  • and similar content.

Usually these folders have tabs that segregate the documents and nearly always the documents are organized so that the most recent document is at the top - this is an illustration of the Last In / First Out principle.

From a volume perspective, in the US, there are approximately 400 patients / doctor overall.  But for primary care physicans, the patients / doctor ratio is in the thousands and likely close to 4,000 patients per doctor.  So, a brand new, single-physican practice after a year will likely have 4,000 charts.  Established single-physican practices have ~10,000 charts and  established multi-physican practices can reach 100,000 charts fairly quickly.

Put another way, doctor's offices have thousands of paper folders stuffed with paper.

If your labor costs are low, then relying on people to manage folders is a good use of money.  On the other hand, as your labor costs rise, the value of automation increases. 

One simple automation is to convert the paper stored in the folders to images and make those images availble to physicians.  We do this by using a piece of hardware known as a scanner - a scanner takes paper and creates electronic pictures of the pages.  Staff then identifies each picture (this is known as indexing) and the picture is added to a software application known as a Document Management system.  In turn, the physician can type the patient's name and all of the scanned documents are listed for the physician to view.  The physician selects a document to view, and it is displayed.

Abstracting this illustration leads one to other paper-intensive markets such as insurance, financial services, government, engineering, and so on.  Abstracting this illustration also leads one to other content-intestive applications, such as law firms, web sites, marketing ,  and so on

While each of the above have unique requirements for which vendors have created specialist applications, they all fall into the broad category of Document Management applications.

Friday, May 7, 2010

Paper Patient Charts in Remote Practices

As hospitals continue their EMR implementations, they often recognize that they need to address the paper that's in their remote clinics and practices:  ie what to do about the paper patient charts in the practices? 

In brief, the following are commonly used:
  • do nothing - leave the paper charts at the practice
  • pack and ship the charts to a central scanning and indexing facility (often at the hospital or nearby and sometimes a third party that specializes in scanning and indexing)
  • use staff at the practice to do the scanning and indexing
  • send a mobile team to the practice to do the scanning

My preference is the mobile scan team and here's why. 

Scanning is Process Manufacturing
While scanning and indexing isn't really hard work, to do it well requires people that like to do it.  Think of scanning as process manufacturing that starts with raw materials (a paper chart) and after processing produces perfectly indexed images inside of an EMR system.  The process includes
  • document preparation - removing paper from the chart, taking out staples and paper clips, repairing paper tears, and taping small pages to 8x11.5 paper.
  • batch preparation - insert document separators to segregate individual documents.  The most common technique is to use barcodes to identify each document type (progress note, lab result, discharge summary etc)
  • scanning - feeding batches of documents through a scanner
  • indexing - adding attributes to each of the documents such as MRN, Date of Service, Provider ID, Facility Code, etc
  • QA - confirming that the image quality is acceptable
  • commital - sending the documents to the ECM system
People that like to do document preparation are essential to creating high quality images in the EMR while people who take pride in their accuracy will prevent misfiles and rework.  Do you have those kinds of people at your remote practices with the time to do chart scanning?

Scanning Requires Specialized Equipment
While the price of scanners has come down, there remains a significant price for performance. Here's how to think about it: if the scanners is running, then paper charts are being converted to images.  If the scanner breaks down, charts are not converted.  My recommendation is to always buy 2 scanners and as operators become proficient whith those scanners, keep the scanners running.  Let the rate at which the scanner scans become the throttle to your process:  add staff to document preparation and indexing / qa to accomodate the throughput of your scanners. 

Additionally, you'll likely want to have tools that make document and batch preparation more efficient such as "spear-type" staple removers, solid scotch tape dispensers, document and batch separators, and so on.