Considerations when using Document Imaging in an EHR
Moving to an EHR does not automatically mean moving away from paper. In practice, most organizations with EHRs use document imaging to integrate paper documents into their EHR. There are many different factors for organizations to take into consideration when implementing or redesigning policies and workflows related to document imaging.
What data to capture as structured data
One question organizations that are implementing an EHR system with document imaging capabilities will want to look at is what elements they wish to capture as structured data. The anticipated use of the data (for example, lab results from a hospital may need to be electronically imported to a primary care provider’s EHR) and the amount of time it takes providers to document the data in a structured format are two factors to be considered.
It is also worth noting that some types of data (such as lab) are easier to view electronically as structured data. Baldwin (2011) gives the example of State Hospital South, where physicians rebelled after “interpreting sequential lab results in the document imaging system proved too difficult."
One of the requirements for meaningful use is documenting the following elements as structured data: patient demographics, vital signs, problem list, medication list, medication allergy list, and smoking status (Baldwin, 2011).
Forms that are designed to be user friendly cannot only help scanning and prepping staff do their work faster, but can also increase the accuracy and quality of the final product. It is easy for busy back office staff to overlook requirements such as having name, date of birth, and date of service on every page. This may not always be caught by scanning and prepping staff, who, especially if they are pressed for time, may look at the first page only. As opportunity allows, redesigning commonly used forms to accommodate labels, can make it easier for staff to consistently meet requirements.
Because they may need to be cut in half before they can be scanned (making the scanned image harder to view), forms that are larger than standard 8½ by 11 paper are another possible target for redesign.
Volume of outside documents received
The number of outside documents that need to be scanned and indexed will vary depending on how many of them can be electronically imported and can be considerable in a large group practice. It has been noted that “while many EHR systems have scanning capabilities, they do not always enable high volume batch scanning needed to keep up with loose reports” (Baldwin, 2011). This may necessitate purchasing additional scanning software.
In a multi-specialty practice, it is not uncommon for some documents to be sent more than once. For example, a hospital document may be sent to the patient’s primary care doctor, the doctor that admitted the patient, and to the surgeon who consulted on the patient. One possible way to manage this is to have documents sent to a central location so that duplicate documents can be pulled before scanning and any priority documents can be indexed and electronically forwarded to physicians for review on a same day basis.
When a patient transfers care and has their records sent from one provider to another, the number of pages can be voluminous. For this reason, it is rarely worth the time to have all of the documents scanned separately, and organizations usually develop a policy concerning what documents to scan (for example, all of the documents or just the documents that the physician chooses to have scanned) and what documents (for example, immunization records and growth charts) to scan separately. These kinds of transferred records are usually scanned into a separate category such as “‘Outside records,’ ‘correspondence,’ or ‘records brought by patient’” (Burrington-Brown, 2008).
Documents with handwritten signatures and/or notes
It is not uncommon for doctors to manually sign documents (for example, a PT status report may be printed out and signed by the referring physician, even when electronic signing is available), to initial documents to indicate that they were reviewed, and to print out a document and handwrite notes. For this reason, it is important that organizational policy concerning documents with manual signatures or handwritten notes is included in the training of scanning and indexing staff and that they are aware of which documents need to be kept as part of the legal record.
Retention of scanned documents
How long to keep paper copies of scanned documents will be determined by organizations based on how much storage space they have and the procedures they have in place for verifying the accurate placement (the right chart and right document type) and legibility of indexed documents. One way to manage this is to have scanned batches labeled with the date they were scanned and the date they are eligible for destruction, so that they can be easily pulled for shredding or for confidential recycling.
Documents that may become part of litigation are a special case. Angela Dinh, MHA, RHIA (2009), states that “In the event of litigation, HIM professionals should always consult with their risk manager and legal counsel before destroying any existing paper that may be related to litigation. Each case will have varying circumstances, and the integrity of the information is paramount.”
- Baldwin, G. (2011). To Scan or Not to Scan; Do meaningful use requirements for 'structured data' spell the end of document management systems? Health Data Management 19(5), 38. 
- Burrington-Brown, J. (2008). In Search of Document Imaging Best Practices. Journal of the American Health Information Management Association, 79(9), 60-61. 
- Clark, J. (2009). Using Document Imaging to Strengthen Revenue Cycle. Journal of the American Health Information Management Association, 80(4), 54-55. /bok1_043251.hcsp?dDocName=bok1_043251
- Dinh, A. (2009). Dealing with Paper Post–Document Imaging. Journal of the American health Information Management Association, 80(5), 54-55. /bok1_043486.hcsp?dDocName=bok1_043486]
- Dunn, R. (2007). Benchmarking Imaging: Making Every Image Count in Scanning Programs. Journal of the American Health Information Management Association, 78(6), 42-46. 
- Gilbert, J. (1998). The Role of Document Imaging in Creating Electronic Records. Health Data Management 6(3), 64. 
- Hagland, M. (2002) Moving Forward with Document Imaging and Never Looking Back to Paper. Journal of the American Health Information Management Association, 73(9), 40-43. 
- Lofton, S. (2000). Ten Steps to Selecting a Document Imaging Vendor. Journal of the American Health Information Management Association 71(8), 22-23. 
- Quinsey, C. (2007). Managing Forms in the Legal Electronic Health Record. Journal of the American Health Information Management Association, 78(7), 58-59. 
- Rogoski, R. (2011). Paperless strategies rely on document imaging: document imaging provides a bridge to the paperless hospital. Healthcare Informatics 28(1), 24. 
- Terry, K. (2006). The easy way to a paperless office: a document management system can give you instant chart access and automate your office without changing the way you work. Medical Economics 83(15), 61. 
Submitted by Susan Denning