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As its first step, a hospital should begin EHR implementation in the health information managementdepartment with an on-demand electronic document management system.

When it comes to embarking on the journey toward an EHR (electronic health record), many organizations first focus on automating the patient floors — as these areas have been the target of hot-button issues such as patient safety through the collection, sharing and analysis of electronic information. High-profile failures with the patient-floor approach — such as Los Angeles’ Cedars-Sinai Medical Center, which scrapped its $34 million computerized physician order entry (CPOE) system after physicians revolted — are leading organizations to wonder whether their journeys might begin in a potentially more valuable setting.

A critical step in creating an EHR is to have a single electronic record of a patient’s entire history, indexed for easy and simultaneous retrieval across functional areas. As its first step, a hospital should begin EHR implementation in the health information management (HIM) department with an on-demand electronic document management system (EDMS).

EDMS: A Vital Component of the EHR

Although an EDMS is often described as an application for the HIM department, this is only partially true. In the broadest sense, an EDMS automates the workflow of the HIM department, providing HIPAA-compliant access to an electronic version of the patient chart. The American Health Information Management Association (AHIMA) divides EDMS capabilities into six categories: automated forms processing; electronic signature, document annotation and edit; document capture (both from paper and electronic sources); document indexing, bar coding, character and form recognition and forms redesign; document retrieval, viewing and distribution; and document management. Thus, although an EDMS primarily supports the HIM department, its effects are felt throughout the hospital and, with browser-based access, extend to the hospital’s associates, such as payers, regulatory agencies, physician clinics and service providers.

According to the AHIMA, HIM computer systems historically have not been included in enterprisewide IT strategies. This has often resulted in two untenable situations: insufficient HIM automation or the housing of a separate information system within the HIM department, one that is not integrated with the rest of the hospital’s IT systems. In both instances, access to the longitudinal patient record is dependent on HIM staff, and the benefits of automation fail to be leveraged from department to department. In addition, most HIM departments are still making paper their primary delivery vehicle for patient information, and even the most efficient, well-staffed hospitals that rely heavily on paper cannot grant simultaneous multi-user access to the patient record.

This is why the EDMS is increasingly being recognized as a critical component of the EHR, the piece that ensures the simultaneous availability of historical patient information to the numerous constituents whose functions depend on this access.

Leveraging the Web for On-Demand Medical Records

Compared with clinical document technologies, which often demand radical workflow changes, a hosted EDMS is relatively low-impact yet has a high return. Although workflow in the HIM department does require change, HIM staff members are able to customize the EDMS to meet the operational realities of their specific hospital.

With a hosted EDMS, the IT resources needed for implementation are minimal, and with almost 75 percent of the typical hospital’s documents created electronically (even though they are still predominantly printed and stored on paper), the majority of the effort required to supply documents to an EDMS is already done; these existing electronic documents require only interfaces to move them into a single electronic repository of patient information. Therefore implementation is relatively simple and quick (six months, on average). In addition, using Internet technologies based on industrywide standards, organizations are able to achieve higher levels of interoperability with other systems, a critical success factor when it comes to information sharing.

Financially, a hosted EDMS also makes a lot of sense. Hospitals do not need to make large capital outlays to get started with a hosted EDMS. The service is an operational expense, with breakevens normally occurring anywhere from six months to 1.5 years after implementation and significant net savings accruing in year two and beyond. In addition, hospitals benefit from a heightened level of technological robustness, security, availability and scalability that they might otherwise be unable to afford.

Stakeholders across the hospital are motivated to participate in the successful implementation and acceptance of electronic patient chart technology because they gain access to records via their Internet browser; employing this familiar tool minimizes training needs and makes getting started with the EDMS very fast and easy. The browser-based approach is particularly helpful for physicians, who can use their Internet browser to view and complete charts without ever coming to the hospital. This seemingly minor triumph is more powerful than one might imagine, as it begins to engender physician support of and participation in point-of-care technology usage.

Any discomfort in changing entrenched paper-based work habits is more than offset by the hosted EDMS’ numerous benefits. Simultaneous electronic access to patient charts means that the chart tug-of-wars that pit, for example, physicians against coders, ER staff against utilization management staff, finally cease. The administrative and clinical efficiencies that result from having more complete patient information accessible at the touch of a computer key, no matter what the time of day and how many others might also be using the information, yield a number of benefits, including the ability to:

• Enhance the revenue cycle by allowing HIM functions to be performed faster, billing to more accurately reflect the services the hospital provides and fewer claims to be denied for insufficient documentation — all along the way ensuring regulatory compliance;
• Cast a wider recruiting net for difficult-to-staff positions like coding, as such functions can be performed remotely — also a prime staff retention factor;
• Improve the satisfaction of physicians and other caregivers by lending greater immediacy, convenience and flexibility to their interactions with the patient record — for example, physicians can sign off on charts from wherever they have Web access;
• Provide better service to patients by giving them a greater sense of being “known” by the hospital — for example, if they visit the emergency room shortly after a hospital stay and records are at a new physician’s fingertips — and being able to both guarantee greater medical record security and share more complete information about who has seen what portion of the record at what time, and what action (e.g., viewed, printed) they took; and
• Reallocate precious hospital space from chart storage to revenue- generating activities and HIM staffing resources to more valuable tasks than simple “paper wrangling.”

In fact, these benefits can be gained so quickly, with so little upfront capital investment, that hard-dollar savings can be used to fund additional EHR components or other needed hospital projects.

Ensuring Security, Availability, Scalability and Speed

The first concern on most people’s minds when the topic arises of using the Internet to share patient information is security. Ensuring the security of patient information on the Internet is a far easier task than ensuring the security of paper records, which can be lost, misfiled, left out in the open and otherwise exposed to inappropriate viewing. The right safeguards are essential, however, and include, at a minimum, hardened data centers, isolation of the data layer from any external access, two-factor authentication, data encryption, access logging, role-based security, automatic log-offs and access control.

For a small organization, providing this level of security may be exceedingly difficult because of the law of diminishing returns: Once a certain level of security is attained, it takes increasingly larger investments to make even minor improvements. These investments are not out of reach for a hosted application provider, as they can be leveraged across a wide swath of clients.

In a hospital environment, the stakes are just as high for guaranteeing the availability of patient information via the Internet. The inability to gain access to electronic patient information when it is required could interfere with the revenue cycle, even jeopardize patient care. Here again, organizations can benefit from a service provider’s ability to invest more heavily in redundant systems and fault-tolerant infrastructure. The ability to cache information within the hospital’s infrastructure also ensures that information remains accessible even when the Internet is not.

Scalability is also an important consideration when implementing an EDMS. Few facilities design their IT infrastructures to gracefully accommodate exponential growth. Hosted applications built on high-performance Web architectures are designed with exactly this in mind. Their basic design includes horizontal cloning, resource pooling, load balancing, “hot” expansion and use of co-location facilities on the Web backbone.

Hand in hand with the question of scalability is the issue of processing speed.Won’t a high volume of users utilizing a data-laden tool over the Internet result in a slow, frustrating system? Web-enabled applications can be slow, as they are front-ending legacy systems.Web-based applications, on the other hand, take advantage of Internet standards that support the delivery of vast quantities of information efficiently and rapidly.Where applications have been designed from the ground up for the Internet, response time is quick, even during high-volume periods.

As a final point, because of the speed of technological advancements themselves, a hospital going at it alone will discover that the quest to be leading edge is an endless and costly one. Partnering with a service provider can give organizations access to the “latest and greatest” without the associated risks, as the success of these companies is largely dependent on their ability to stay ahead of the technology curve.

Interoperability With Other Systems

To arrive at a complete EHR, organizations need to take a component- by-component approach because of the sheer size of the project. Each component needs to work with the next component, which means that the components should be built on industry standards such as XML, HTML, Health Level 7 and others. Nonetheless interfaces to these systems can and should be created to maximize the efficiency and usefulness of the added components.

Service providers often have an advantage here, as they interface with multiple legacy applications. Their experience in creating functional interfaces can be applied to the implementation process and ensures quick results. Hospitals are advised to start with a connection to their admission, discharge and transfer systems; updates here should automatically be reflected in the hosted EDMS to help maintain a cohesive record. Optimal next targets are transcription, laboratory, pharmacy, the emergency department, computerized physician order entry and radiology. Hospitals can then move on to capture, via interface, any document that was created in electronic form.

Extending Beyond the HIM Department

The final reason to start EHR implementations with a hosted EDMS is the number of external organizations the HIM department touches that will also benefit from electronic information access. Remote workers, outsourced service providers, auditors, government agencies and others with a rightful need to view the patient record can gain access under tightly regulated conditions. Data bridges, in turn, help hospitals build stronger, more efficient and profitable relationships with these business partners. A hosted EDMS allows only secure, authorized and auditable access to medical record information, so a hospital does not have to balance the risk of exposing its technology infrastructure to outsiders against the advantages of broadening access.

In addition, organizations should consider that a hosted EDMS’ utility can extend beyond the HIM department and its functions — for example, to “de-paper” the business office, to support clinical research and facilitate the development of evidence-based clinical guidelines, and even to replace the majority of filing cabinets in the facility devoted to duplication or long-term storage of medical record information.

Into the foreseeable future, paper will be generated in the patient care process that will need to be managed, records will still require authentication and completion, payers will require documents to support claims, records will be subpoenaed and delivered into jurisprudence and, perhaps most importantly, historical data that did not originate electronically will be required in the patient care process. That these functions may need to be performed simultaneously means that the hosted EDMS is now and will continue to be an essential component of the EHR.