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Health IT and EHRs: Principles and Practice, Sixth Edition

Chapter 18: Enterprise Content and Record Management as an EHR Bridge Technology

Bridge Technologies as an IT Strategy

For many years, electronic document management (EDM) systems were considered bridge technology for EHRs, making paper documents that were still prevalent available electronically.

While there is still need to fill gaps where records are not electronic, enterprise content management (ECM) systems that are generally more advanced than EDM are complementing EHR components and serving additional, other uses

Sources & Uses of Content Aided by EDM

Photos

Voice files

Video

E-mail

Digital pen and paper

Fax

E-forms

Scanned images

Paper

Web content

Social media content

Health app data

HOSPITALS (workflow management)

Coding

Chart analysis & deficiency completion

Data abstracting

Transcription

Release of information

Responding to requests for access, amendment, and accounting for disclosures

Tracking paper records

PHYSICIAN OFFICES

Overcoming choppiness of information in EHR through POISED

Clinical messaging support in physician offices

Chart conversion

Hybrid Records

In the current acute setting, one of the following situations may represent the current state of health records:

Some parts are on paper only and some parts exist electronically only.

Some parts are on paper only; some parts are electronic, but ultimately printed to (and stored as) paper.

Sometimes these printouts are scanned back into the ECRM system so there is one source for all data.

Some parts are on paper only; some parts are electronic only, but are routinely requested to be printed out during patient care episode.

Nature and Use of Information Content

ECM Technologies

Three levels of patient information management tools

Level 1: Document imaging systems

Level 2: Document imaging and management systems

Level 3: Electronic document management

Enterprise content management (CDM) systems are successors to Level 3 and address:

Content (vendor neutral archive [VNA] platform)

Processing

Use

Long-term archiving

Enterprise content, collaboration, and communications (EC3M) systems (information as a service) add collaboration and communication to EMC (such as groupware)

Risks in Hybrid Records

Authoring and printing issues

A physician may request a print-out of electronic information or scanned document, write on it (or not) and it later gets scanned into ECRM, creating a duplicate.

Printing is burdensome for nursing unit or other place where it occurs

Printing and documenting on what should be electronic only may result in patient care action or inaction that is wrong as a result of not seeing the documentation on the printout.

Access and disclosure issues

Where is the record? Some clinicians may not want to look in electronic system, others may not want to look for paper – so patient care issues can result.

Printouts may not be appropriately discarded, can be carried away for legitimate future reference, but get lost.

Operational issues in HIM department

ECRM in Hospitals

Enables a paperless environment

One place to look for everything

Reduces the risks of a hybrid environment

Does not eliminate them if clinicians are allowed to print

Some hospitals fill their printers with colored paper to identify a copy on which not to document and not to be scanned

Supports the creation of a legal health record because it ensures that what is generated from an EHR is printable

ECRM in Physician Offices

Aids in chart conversion

All parts of an EHR are usually implemented at once as part of a comprehensive product

Records of currently active patients, however, need to be made available via EHR

Active charts may be:

Scanned

Abstracted

Combination thereof

Combined with clinical messaging, can support all forms of digital information

ECRM Technologies

From narrow to broad focus

Document scanning and imaging systems

Electronic document management systems

Electronic record management systems

Electronic content management systems

Together electronic content and record management systems

Enterprise content, collaboration, and communications systems

Convergence of ECRM Technology

EDM/ECM Systems Acquisition, Implementation, and Use

Selection process similar to any health IT system

Considerations for consolidation of systems

Vendor experience

How disparate are organizations

Consolidation experience

Sophistication of technology

Volumes and workflows

Need for next level of technology

Reduce volume of documents in other ways (scan on demand)

Implementation Considerations

Person identification

EMPI

Positive patient identification

Document indexing

Real-time location systems

Forms identification and design

Version control and authentication

Access control and audit logs

Record categorization

Workflow management

Preparation for use

Physical environment

Monitoring work performed

Document Indexing

To enhance retrieval, scanned or electronically fed documents should be indexed.

Most common form of indexing is application of a bar code that supplies the type of form.

Code 39 (or linear bar code) is basic, and required by FDA on all drugs and biologicals. Standardized by Health Industry Bar Code Council (HIBCC)

Code 128 (or two-dimensional) can encode more complex information. Produced by Uniform Code Council (UCC)

Radio Frequency Identification (RFID)

Optical Character Recognition (OCR)

Forms Identification & Design

Optical mark recognition (OMR) – oldest; easy to use, yet lacks flexibility

Optical character recognition (OCR) – significant adjunct to data entry, though newer technologies replacing

Intelligent character recognition (ICR) and optical word recognition (OWR) – advanced form of OCR in which system learns (through artificial intelligence) to recognize handwriting (Similar to speech recognition)

Intelligent word recognition (IWR) – newest technology that recognizes unconstrained handwritten words

Document Management

Version control

Preliminary versus final copies of reports

Incomplete versus complete documents

Signed versus unsigned documents

Automated forms processing presents unique challenges in documenting date or time each entry was made. Usually assumed all entries were made at same time and in close proximity to when scanned

Access controls and audit trails to provide permission for use and track what access has been made

Authentication

Electronic signature is legal under ESIGN Act and as states have adopted UETA

Documents may be signed and scanned

Documents may have a digitized signature applied

Documents may have an electronic signature applied by virtue of userID and password, biometric, or token used to provide authentication

ASTM E1762-95 (2013) Standard Guide for Electronic Authentication of Health Care Information

HL7 EHR-System Records Management and Evidentiary Support Functional Profile (2010)

Also important are:

Amendments, corrections, and deletions

Workflow Management Systems

Not all ECRM incorporate workflow. Not all workflow systems can perform all types of workflow.

Stores workflow definitions as a collection of tasks, resources, and conditional logic in a workflow engine

Assembles information needed to perform a task: e.g. records to be coded

Provides guidance for performing each task according to correct and consistent business rules: e.g. Medicare charts must be coded by Medicare coding specialists within 2 days of discharge, who are expected to code 20 charts per day

Routes the task, along with the information needed to perform it, to the appropriate person

Divides tasks or parts of tasks, coordinating the work of multiple people on the various parts, and reassembling the parts to complete the original process

HL7 C-CDA

HL7 Clinical Document Architecture (CDA) enables documents to be generated from EHR and transmitted directly to any type of recipient

As a MU requirement, it should:

Decrease the volume of release-of-information (ROI) requests because patients can retrieve these through patient portals or put on a flash drive

Lower costs of ROI as documents can be generated and transmitted with out paper processing costs

Increase physician adoption of EHR as such documents “tell the patient story” in a manner with which physician are more accustomed

Reduce costs of providing documentation to health plans for prior authorization and claim attachments

HL7 C-CDA Transmission

CDA is a document markup specification that can be transported in a variety of means, including:

Attachment in a standard HL7 V2.x message or embedded in an HL7 V3 message (see Chapter 13)

Integrating the Healthcare Enterprise (IHE) Cross-Enterprise Document Sharing (XDS) Profile further enables specificity for exchanging HL7 messages

DICOM message

MIME-encoded e-mail attachment

HTTP over the Web

File Transfer Protocol (FTP) through any client/server network

HL7 C-CDA Document Architecture

The C-CDA set of document templates is a flexible document markup standard with a mandatory free-form portion enabling human reading and an optional XML-structured part that enables electronic processing. LOINC codes are used to identify each type of document.

CDA Building Blocks

CDA is a set of building blocks of related data that can be moved into various documents as needed: