We’ve all had the experience of reading a book, then wanting to look back on an especially important piece of information. We page back and forth, looking for a page whose contents we clearly recall, but cannot locate. The bigger the book, the longer the search.
For behavioral health providers, the costs of retrieving information stored on paper in a patient’s chart goes far beyond the inconvenience of losing their place or misplacing the chart. The biggest cost of having paper records is having a place to put them—literally, it’s the cost of the square footage in the office, or at a secure offsite storage location.
Records storage requirements don’t make the burden any easier to bear, either, says Carl Clark, MD, CEO of the Mental Health Center of Denver (MHCD). “You have to keep even ‘closed’ patient records for seven years. It’s a huge volume of paper and it costs a lot to store.” It also costs plenty to manage: as recently as 2009, MHCD employed two individuals at each of eight sites to manage records, schedule appointments, and welcome incoming patients.
After going live with its first electronic health records (EHR) system 10 years ago, in October 2003, Clark said his team found that an EHR system was only the first step in going paperless. “There’s still that interface [after the system go-live date] where you have paper,” he says. That means all of the charts and records that existed before the EHR went in, and all of the paper—letters, faxes, lab reports, legal documents, and more—that keep on flowing into any provider office as part of a consumer’s treatment and services.
Why go with an ECM solution?
There wasn’t any “one” thing that made an enterprise content management system essential at MHCD. “It was more the frustration with ‘Where is the chart? Where is the paper record?’” Clark explains. Noting that he still sees patients himself, he cited this as a typical situation: “If a patient is in and not doing well on his current medication, I’ve got to reevaluate and make a change.”
However, since MHCD’s EHR previously contained only “going forward” records—electronic records dating forward from October 2003, Clark said that past medication information often wasn’t available in the EHR. As a result, “I’ve got to ask somebody to go find that paper record. That takes some time. Then, when they bring me the record, now, I’ve got no way to sort it—there’s no way to get right to the medication notes. So, I’m looking through that chart page by page. It’s not impossible, but it takes a while.” The effort is essential to avoid prescribing a medication that may have failed in the past.
One solution to all that paper chasing is to get rid of all those old paper records by digitizing them. But there’s a lot more to the process than scanning pages into digital print document format (.pdf) files and saving them onto a hard drive. Today, the process of ECM, or enterprise content management, not only stores the digital scans, but enables the customer to load them—as part of the scanning process—into a pre-planned, configurable, and searchable index structure that simplifies records organization and dramatically improves records retrieval.
To imagine the kinds of ECM record structure it would need, MHCD did a lot of advance work, Clark says. “We involved clinicians, psychiatrists, social workers, case managers, quality systems and health information people, because different people have different processes and needs. We looked at their workflows and asked, ‘How do you want this record to be? What are you trying to retrieve?’ We also designed the system to support outside auditors and reviewers.”
Indexing paper documents using an ECM system
This—the organizing and indexing part of the process—is the part that makes an effective ECM solution work, explains Mary Peelen, MHCD’s manager of health information systems. She worked with the local reseller/vendor for Digitech, whose PaperVision Capture and PaperVision Enterprise software were used to build MHCD’s ECM solution.
Citing an example—the need to store a signed Advance Directive—Peelen said that the indexing and storage process can be done manually this way:
1) Scan the document to “capture” it.
2) Enter the consumer’s ID number to retrieve the index of that consumer's electronic medical record. (Note: if the paper record is specially barcoded, steps 3-5 are completed automatically.)
3) When the record “index” is shown, select the section into which the document should be placed. Note that LEGAL is selected.
4) Next, select the appropriate subsection under which the scanned document is to be stored. The LEGAL section of an MHCD consumer record contains numerous subsections, including ADVANCE DIRECTIVE, which is selected.
5) “Submit” the information to the system.
Upon submission, two things happen to the scanned document: First, it is passed through a powerful optical character recognition (OCR) program that converts inked-on letters into readable, searchable electronic text. (This text can be exported directly into an EMR, but MHCD doesn’t use that capability at present.) Second, the document is linked to the relevant section/subsection of the patient’s electronic medical record, where it can be opened with a click and displayed in or alongside the EMR system interface.
Managing the ECM process
Peelen said that integrating the scanned documents with MHCD’s electronic medical records system, Netsmart’s CMHC, was straightforward, requiring a bit of custom code. According to Digitech’s VP of Business Development, Sean Morris, such EHR integrations are common and relatively easy to accomplish.
There were a number of options available for doing the actual scanning, though MHCD elected to do the job in-house after a short training course. Over a period of five years, starting in 2006, MHCD scanned the contents of 15 medical records rooms at eight different treatment sites, each of which contained up to 900 detailed patient records. Millions of pages were involved.
“It took us five years to scan the records, and we had to reorganize all the [records management] positions at each site because those people wouldn’t be managing those records in the same way,” Peelen explained. The scanning and indexing process and hardware was conducted from a central location, with records sent in from each of the sites. In many cases, the boxed-up records arrived in pallet-sized loads, part of a pre-planned sequence that included:
- All active consumers (paper records scanned back to EHR go-live date, October 2003)
- All consumers after October 2003 (paper records scanned from that date forward)
- All psychiatric assessments, psychiatrist notes, and labs for the above (paper records from 2000 forward)
Along with the process of digitizing active patient records, MHCD also developed procedures to digitize all incoming paperwork from consumers or third parties (consents, documents, court findings, lab work, third-party provider reports, etc.). These items are scanned and indexed into patient medical records on an as-received basis, Peelen added.
While both Clark and Peelen agree that the financial payback on the ECM system has been very positive—a Nucleus Research study claims a six-week payoff and a three-year ROI averaging 1315%—he maintains that the benefits go beyond ROI. “This has made the life of the clinicians better. They can find this information fast. That’s great,” he says, noting that once improved convenience, workflows, and productivity “become the expectation,” they tend to breed new ideas, higher expectations, and better results” throughout the organization. Changes like that “make a place a great place to work.”