March 10 , 2008

Caging the Paper Tiger
By Annie Macios
Radiology Today
Vol. 9 No. 5 P. 10

Integrating digital documents, RIS, and PACS can reduce paper and make medical data storage and transfer more nimble.

In any healthcare facility, streamlining work processes and eliminating misplaced paperwork is good. However, finding the best way to make it happen isn’t easy. When Central Oregon Radiology Assoc., P.C. (CORA) in Bend, Ore., decided to digitize nearly every aspect of its operations, it developed a three-point plan to achieve this goal. The initiative involves digitizing the following workflow components to be sequentially phased in and integrated:

• PACS to store and manage radiological images, transcriptions, and medical information;

• RIS to manage appointment scheduling and billing; and

• a digital document management system to store and manage consent forms, explanation of benefits (EOB) forms, and other documentation.

Marico Oliveira, who was the director of operations when the decision was made and is now CORA’s director of human resources, says the impetus for a paperless environment came when they implemented PACS for images. “Since we were in digital imaging now, we began to look at where we could reduce paper elsewhere,” she says.

Making the Move
Oliveira learned about Laserfiche, a document management solutions company, and the services it offers at a CPU Medical Management Systems user’s conference. CPU, which is CORA’s RIS software provider, found that many users wanted to integrate digital document management technology with their RIS application, so they initially offered a basic version of a document imaging system in an effort to meet their customers’ needs. In the end, however, CORA believed Laserfiche could offer a greater amount of flexibility and options, so they formed a partnership.

“After seeing a demonstration of how much Laserfiche is capable of, we realized this would help us in our decision to go paperless,” says Oliveira. And because the RIS vendor and Laserfiche are partners, the possibility of using the programs side by side eliminated the paper shuffle, she adds.

“Once we made the determination and cost justification, choosing Laserfiche was an easy decision, and it was also really easy to implement,” says Oliveira.

Integrating the Components
Mauricio Pinto, director of healthcare solutions for Laserfiche, describes how document management can be streamlined, reducing the so-called paper trail that pervades many healthcare facilities. “When you minimize paper-based activity and work in a digital environment, you trim costs,” says Pinto. The application takes over after a scanner converts a document into an electronic image. More people are scanning today, but the challenge, says Pinto, is, “How do I store it securely, and how do I find it again when I want it? In fact, how do I find a phrase or single word in a large document?”

To create an environment where data retrieval is simple, the solution needs more than a smart naming convention, he says. So Laserfiche created a product that enables users to quickly locate documents, automates the information capture process, routes documents through an electronic workflow, and audits user activity. The repository provides a regulatory, security-compliant site to store and access documents where users can organize the documents in a way that makes sense for their organization.

The ultimate goal in implementing an electronic document management solution is to quickly find records. Laserfiche’s technology extracts every word in a document and allows users to assign data fields to each record so it can be retrieved using a variety of search tools. For example, a facility such as CORA can search for a document based on the date when service was provided, by patient name, or by a word related to the procedure. Advanced search capabilities include folder structure navigation in combination with full text search, template field search, and searches on known properties about the record. “Wildcarding” and “fuzzy” search capabilities offer the ability to search even if the user is unsure of the spelling of the search term.

Once the document is found, it can be routed to someone using electronic workflow capabilities. At CORA, if a patient gives his insurance card to office staff, they can instantly scan it, create a folder for the patient, and generate the workflow that routes the information to the billing department without having to manually move a file.
The auditing capability enables a user to choose a file or a document and see everyone who has “touched” the case, which is beneficial for ensuring the continuity of care and completion of business practice procedures such as billing.

Laserfiche’s technology meets HIPAA and Joint Commission requirements with multiple levels of access control, from initial system access to controlling the departmental silos to group or individual folder and records access, as well as field and word-level visibility. “At our facility, HIPAA guidelines are conformed to by having appropriate levels of access in place. User rights and group rights were set up that protect access to folders and documents, which guards the integrity of the data,” says Oliveira.

Electronic redaction tools enable staff to obscure sensitive information, which is especially useful when they need to send EOBs—which typically contain information related to multiple patients—to a secondary payer.

Getting the Records Straight
To begin the transition to a digital environment, human resources personnel were tasked with scanning all the old documents, which Oliveira says was handled in a methodical manner. “They were done by department, so we set a goal to get to a certain point by a certain date and just kept on track in completing the task in that way,” she says. Once all the records were accounted for and functional in the new system, the old records were shredded.

“Rather than doing the scanning on the back end [as was done for existing records], the goal is to have it all done on the front end as documents come in and are created. We are getting there, for example, with having the EOB and billing information in the system,” says Oliveira.

Workflow Improvements
A proper solution for managing documents should offer an electronic replacement for manual processes, according to Pinto. Advanced workflow functionality securely routes records organizationwide and optionally alerts appropriate personnel to action if necessary. Staff can e-mail or fax from within the application and download records to CD, DVD, or USB drives if their security setting allows. Electronic workflow can sequentially alert each staff member that work is waiting.

With the ultimate goal of integrating PACS, RIS, and its digital document management system, CORA has already seen substantial improvements since incorporating Laserfiche’s technology. Currently, all the medical images and related documents at CORA are stored in PACS, and the staff is using Laserfiche for everything else, including the exam orders, patient IDs, and insurance cards. The billing department uses it to process insurance payments and to store and manage the often exhaustive EOBs, as well as other documents such as waivers. Even items such as board meeting minutes and human resources records can be placed into the Laserfiche repository.

“When we went live with Laserfiche, workflow improved tremendously. Before when you needed a file, someone would have to manually retrieve it, and if more than one person needed access at the same time, it created problems. The change in workflow was substantial because we are no longer dealing with the manual processes. It also cuts down on lost or misfiled documents, which can consume a lot of extra time as well,” says Oliveira. She mentions that users also like the system’s availability and ease of use.

Putting It All Together
This technology, when rolled out in a radiology practice, can effectively streamline records management and reduce or eliminate paper when it is incorporated with a RIS and PACS. For RIS, nonclinical documentation such as that related to insurance, scheduling, patient demographics, and billing offers a multitude of opportunities for eliminating paper files. Essentially, all paper that comes from outside the organization, as well as internally generated documents, can be managed through a document management system.

Document management is especially helpful with billing. The billing department can instantly figure out when the file is ready for coding and billing, and, in turn, payment follow-up. “Checks are often received from a payer with a large batch of paper EOBs. With Laserfiche, those documents are scanned in and all text is extracted. This eliminates having to physically store the paper, and billing can simply search for a name or account number or date of service to locate a transaction,” says Pinto.

The RIS serves as the midpoint application and common data source, integrating with both Laserfiche and the PACS for medical images. The integration makes sure the medical record number is consistent across all three applications, ensuring accuracy and consistency.

Ready, Set, Action!
Pinto explains that from front to back—from when a patient schedules an initial appointment to when he receives services to billing and collections—Laserfiche serves as the electronic filing cabinet. While RIS and PACS specifically manage clinical data, the system can be used in accounting, human resources, credentialing, and facilities maintenance. And the ability to use the technology as a stand-alone process or integrated solution offers flexibility and room for growth.

CORA is on the verge of integrating Laserfiche into its RIS. In doing so, Oliveira believes that they will continue to reap benefits and reduce the paper flow even more. “We are doing so much already in our initial phase, but we realize how much more Laserfiche is capable of and are looking forward to implementing the integration to take advantage of as much as possible. There is so much available, we have to implement it in phases,” says Oliveira.

Typical RIS integration starts with a real-time search for patients, either creating a file for new patients or retrieving current information for existing patients from the RIS and populating index fields in processed records, which helps to avoid double entry and errors. Pinto mentions that Laserfiche does more than convert paper documents; it also stores and manages existing electronic files such as e-mails, digital sound files, and image files that aren’t generated by the imaging modalities. Further integration allows retrieval of stored documents from within the RIS application.

Although Oliveira realizes that CORA will never be completely paperless, the move to digitizing operations will streamline processes tremendously and offer more benefits as additional levels of implementation and integration are brought onto the system. The implementation team has put the system into place with great success in other areas of the facility such as the human resources department. “Interoperability, where the various departmental applications can talk to each other, is key in achieving the best efficiency and the greatest benefits to an entire operation,” says Pinto.

— Annie Macios is a freelance writer based in Doylestown, Pa.

Applying Document Management Solutions FacilityWide
Any paper-intensive department or one striving to become paper free can benefit from an electronic document management solution. With a stand-alone application, each department or functional area can establish its own secure records silo with unique folder structures, index templates, and user-defined workflow rules.

A good document management solution must do the following:

• manage both paper and disparate electronic record formats;

• normalize all records in a single, nonproprietary, and nonalterable electronic record format such as TIFF;

• extract and store data separately for searching;

• store records in a secure repository that limits access by user and/or folder, document, and data field;

• organize data in a way that suits office workflow; and

• offer powerful search capabilities.

From the front desk to the back office, electronic document management solutions create efficient, streamlined operations and help the business of healthcare focus on patient care, rather than shuffling paper.

— Source: “Simplifying the Business of Healthcare”, Laserfiche Healthcare Whitepaper, 2007