A giant step forward: a specialty practice goes entirely paperless by combining electronic document management technology with its existing EMR - What works: document management - Capitol ENT

Health Management Technology, Oct, 2002

For many physician specialty practices, "going paperless" is a major objective. But the challenge is not always in the "going" portion of that phrase. Sometimes the real challenge is in staying paperless. It's not as easy as it sounds, and it may require adding one technology to another, as we discovered.

PROBLEM

Capitol ENT is an ear, nose and throat specialty practice with three locations, six physicians and 50 additional employees serving 120 to 140 patients a day in the Raleigh, NC, area.

We pride ourselves on being technologically advanced. For 10 years now, we have used an electronic medical record (EMR) for ENT patients, with no paper charts maintained on any patient. Our EMR, called Entity, has registration, scheduling and practice management capabilities, as well as a module for progress notes. Our nurses and medical assistants--and even physicians--were accustomed to keying in ICD-9 and CPT codes after each patient encounter. Also, physicians can enter prescriptions electronically. In short, we felt well equipped to manage electronically all documentation that we generated in our office.

But we still suffered from paper overload, and we found ourselves unable to contain it since it originated from external sources. In fact, we estimate that we handled about 1,600 pieces of paper per day for our patients. Day in and day out we dealt with patients' insurance cards, lab results, referring physicians' orders, X-rays, explanation of benefits (EOB) forms, sleep study results, claim documentation and paper charts that patients would bring with them from referring physicians.

Any physician practice that has succeeded in going paperless knows that one of the hazards of the electronic office is a shortage of storage space for paper documentation. Most organizations that succeed in creating a paper-free climate manage to quickly reallocate precious storage space for other purposes.

In our case, we had so little storage space available that we had to box up all the excess miscellaneous paper documents and pay an outside source for storage--which meant we incurred additional fees for document retrieval as well.

We were also concerned with HIPAA compliance and wanted to maintain our proactive stance. We didn't want extraneous papers floating around the clinic area or exam rooms where they could be seen and read by unauthorized persons. We even planned to move to a single sign-in sheet per patient to meet HIPAA regulations.

Of course, a serious downside to maintaining paper was that none of our physicians ever had a complete and comprehensive patient record to view on the computer screen. As complete as our EMRs were, the abundance of paper support documents stored away at an outside facility still posed a tactical disadvantage to our physicians.

SOLUTION

We realized that we needed a document imaging system that would integrate with our existing EMR to help us become totally paper-free. In October 2001, we selected IMPACT.MD[TM], a medical document imaging systems from Advanced Imaging Concepts (AIC). This is a Windows-based system that scans into the electronic chart support or extraneous paper such as telephone messages, insurance cards, and external lab reports that otherwise have no way of easily being incorporated into an EMR. Once in the system, these images can be organized and indexed just like paper medical records.

AIC worked with Entity to create an interface between the two products. For example, if we are in the EMR, we can go straight into IMPACT.MD where the majority of the chart now resides. We still use the EMR to enter patient encounter data and track patient care, and our electronic prescriptions and QA forms come from the EMR, too. But we have abandoned the use of its progress notes and document management modules and are using IMPACT.MD for those functions, as well as storing the entire patient chart.

RESULTS

Within a week of installation, we were functional with the document imaging system. We chose to start with check-in and check-out, and began with insurance cards.

Scanning. We wanted to scan as many insurance cards as we could at check-in. Yet, we wanted to take our time with this process and track our efficiency so we could implement the most efficient method of scanning. We were concerned that sometimes too many patients stand at the registration window simultaneously, and we were not sure we could handle all their insurance cards at once. Our initial plan was to scan the cards that we could, and copy the others to scan later. But by the second week, we could scan every insurance card for every patient as he or she arrived with no preliminary copying necessary.

Transcriptions. We set a target date of November 1, just a month after installation, for all transcriptions to be entered into patient charts via document imaging. We converted our transcription to Microsoft Word, and the transcriptionist could enter directly into IMPACT.MD. We now have progress notes going directly into patient charts with 24-hour access for physicians. Also, physicians can sign off on documents in just two or three minutes. In addition, nurses and physicians can view a list of documents for one patient and see at a glance those that need to be signed.