Some healthcare IT executives see document imaging and management systems as a stopgap measure on the road to full-featured electronic medical records (EMRs). For others, the path to an EMR is not so clear, and document imaging holds the promise of immediate delivery from mountains of paper. Still others — already implementing EMRs — find they need both types of systems. But the $64,000 question about document imaging is: How does it fit into a long-term IT strategy?
"The Holy Grail may be a giant database with everything codified and accessible with decision-support tools," says Michael Cohen, president of MRC Consulting Group of St. Charles, Ill., but some hospitals aren't yet ready for the expense or the effort that will take. "For them, document imaging is more of a straight shot to get to the benefits quicker," he says.
Hospital business departments find document imaging valuable because its workflow management tools can route documents to the right people at the right time and strip steps out of a process. "There are lots of cost savings in driving paper out of the business side of healthcare," says John Mancini, president of AIIM, a nonprofit membership organization of enterprise content management companies. He noted that in a 2006 AIIM survey of health IT executives, 34 percent said scan and capture technologies delivered a better return on investment than other IT investments, and 16 percent said the return was much better.
But if document imaging's value in business applications is clear, its role in clinical settings is more complicated. One of the key distinctions health IT executives must weigh is that EMRs are data-driven and lend themselves to clinical research and decision support tools, while document imaging systems are mainly object repositories. They create electronic versions of patient charts but do not allow for data manipulation.
Cohen, who consults with hospitals on EMR implementations, tells clients they must consider how document imaging fits into their long-term plans.
"My concern is when hospitals jump into a document imaging system thinking it's going to get them to the same place as an electronic medical record. Because down the road they may find it won't get them where they want to go, and then they might have to duplicate the system," he says.
John Vines recalls that after years of searching, the administrators of Campbell Clinic Orthopedics had just about given up finding an EMR to their liking, despite a growing need. "We were dealing with lost charts, charts out of order, lots of paper, and lots of staff to handle paper," says Vines, CEO of the Memphis, Tenn.-based sports medicine clinic comprised of 36 doctors and four locations.
"We test-piloted a number of EMRs, and in each case the doctors were losing interest because they became data input people," Vines says. "It just didn't make sense to shift that work to the highest paid people in the organization."
Campbell then began looking at simpler programs that involved scanning paper-based records into a database. In early 2005, the clinic implemented Montvale, N.J.-based SRS Software's "Easy EMR." The advantage, Vines says, is that doctors can continue to document patient visits in the same manner they're used to. Their transcribed notes are entered into a central database, and can be pulled up by staff members at the clinic's four sites. The SRS system is integrated with Campbell's practice management software and its picture archiving and communications system (PACS), so doctors can go from the chart to x-rays with the click of a mouse.
But Vines says the Campbell team knew the product had limitations. "We do refer to it as EMR Lite," he says, "because it doesn't offer the full functionality that some products do."
Campbell is involved in several research studies, so the unstructured nature of scanned-in data which limits searching capabilities "was one of our biggest concerns," Vines says. "But only a small percentage of our patients are involved in clinical studies, so we decided that to make our product decision on that factor would be the tail wagging the dog. We felt it was more important to make sure the doctors are doing their work efficiently."
Imaging and the EMR
Many large health systems that take the EMR plunge find they need complementary document imaging systems. For them, integration is the mantra.
For instance, in 2004 as Minneapolis-based Allina Health System IT executives and clinical leaders began work on their ambitious Excellian EMR, based on Epic Systems (Madison, Wis.) technology, they realized they needed document imaging because paper documents such as lab reports and consultation letters have to be integrated with patient records.
The question for Allina, which operates 11 hospitals and 65 clinics, was how tightly integrated the document imaging product could be with the Epic EMR module it had already chosen. Document imaging became "part of an enterprise-wide strategy and the driver was the EMR," says Susan deCathelineau, Allina's enterprise document management system manager.
After looking at seven products, Allina's search committee chose Westlake, Ohio-based Hyland Software's OnBase because of the company's ability to customize the product to work from within other software. "They have to be able to seamlessly integrate with business-line applications," deCathelineau says. "We can't have users toggling back and forth" between the document imaging software and other applications.
After a deal was signed, it took about six months of coordinated programming by Epic and Hyland before the first Excellian clinical implementation began in July 2005. DeCathelineau says the product integration has been impressive. "In most cases, the end-users don't even know they're using different applications," she says, "so there's not a double learning curve."
As of March 1, Allina had completed rollout at three hospitals and 40 clinics and expects to complete the project in 2007.
Document imaging can be viewed as an interim step toward an EMR, says Cohen, but buyers should work with a vendor that also offers an EMR product or at least can show a clear path to becoming interoperable with one.
"When you walk the floor at a trade show," he says, "many of the stand-alone document imaging vendors have no path or map to an electronic medical record." That, he adds, should be a red flag.
Children's Hospital and Health Center of San Diego is currently evaluating EMRs, but in late 2002 it implemented document imaging as a bridge to get there.
"Ultimately, we want an electronic health record that contains everything: documentation at point of care, physician order entry, and decision support capabilities," says Cassi Birnbaum, director of health information, "but we realized we weren't going to get there overnight." Meanwhile, the hospital was "drowning in paper," she says. It was falling months behind in filing, and physicians were dissatisfied because charts were not always readily accessible.
Children's bridge strategy involves the ChartMaxx document imaging system from Mason, Ohio-based MedPlus Inc., which Birnbaum says is more than just a scanning solution.
"In our ambulatory facilities, it features tools to make work flow more efficiently," she says, and it has helped cut down on chart completion times. She says when an EMR is selected, ChartMaxx will continue to handle several key document imaging and workflow functions. For instance, ChartMaxx offers a physician portal to allow for single sign-on to multiple systems.
"That's a really handy tool and if the physicians like the look and feel of it, we can overlay it on the EMR after implementation," Birnbaum says. Although an EMR is clearly on the horizon, ChartMaxx has been a good interim solution, she says. "It gives us some breathing space."
David Raths is a freelance writer based in Portland, Maine.