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They also provide the capability to render an exact copy of a patient record for legal purposes. That isn't true of most pure computerized patient record (CPR) systems that support only structured (numbers and letters) data. Those CPR systems are fine for diagnostic and longitudinal clinical evaluations. However, very few organizations have convinced all caregivers, staff and payers to go "paperless," and, if they have, the public that they serve certainly is not there yet. As an example, a patient will usually contest a charge in writing, and that letter must be intelligently tracked and linked securely to the financial folder or related episode in the EPR. Questions, such as, "When was this correspondence received?", "What have we done with this inquiry?" and "Where is our supporting documentation?" need to be answered.
Managed care organizations more and more are processing claims electronically, and receiving the documentation for those claims electronically. Physician groups are driving inefficiency out of their practices by increasing automation--including access to patient records, treatment guidelines and reference databases regarding efficacy and cost of various courses of treatment.
There has been a significant change that has occurred in the past year or so. The healthcare industry, particularly acute care facilities, in the midst of a flurry of merger and acquisition activity, has discovered they lack the ability to move quickly internally to assimilate new systems and adapt to the changing environment. Quite inefficient and labor-intensive business processes are still being used. When acquisitions or mergers are made, the integration of Information Technology (IT) systems, Standard Operating Procedures (SOP), and elements as mundane as utilizing common forms have greatly slowed progress. An even more threatening development is the voraciousness of the federal government in demanding documentation submitted for Medicare/Medicaid charges.
Many organizations derive more than half of their revenue from this source, and it is only a matter of time until "Big Brother" comes knocking. If organizations are able to justify their actions with a clear and indisputable audit trail, they will avoid repaying monies collected from the government, potential financial penalties, and possibly even continued close scrutiny. That is to say, if your organization has automated systems in place where documentation is readily available, proven to be reliable, with proper audit and backup procedures in use, maybe they'll move on to the next healthcare organization--one which cannot demonstrate such efficiency and accuracy in operations.
What is further driving change and the increased rate of adoption of electronic document management systems is that patients (and physicians) are now being viewed increasingly as customers. These customers want to deal with efficient organizations that tend not only to their healthcare services needs, but also to the business needs associated with those services. To make it fast and easy (but not mindless) for a physician to complete attestations with a secure, electronic signature, makes working more pleasant for physicians. Of course, they are human, and in this new competitive, less-regulated (but more audited) world, healthcare organizations need to address the business and administrative requirements of doctors, not just clinical ones.
The same goes for patients. They want to know what action has been taken regarding the recent letter they sent to Patient Financial Services. They want to get a live person on the phone in the Business Office who can pull up their file and discuss it intelligently with them. Patients or guarantors may want more detailed descriptions of charges on their bill. They want answers, and manually putting them on a list that may or may not get the attention they require just isn't good enough anymore. They have choices. One bad experience and they will go elsewhere for healthcare services, if they can.
There is a term that has arisen to describe a set of technologies that can make organizations smarter and more responsive, and leverages information that already exists within the organization. It is generically called knowledge management (KM). The rapid increase by healthcare concerns in the evaluation and acquisition of this technology set is quite evident. In one survey, nearly 90% of hospitals were said to be actively piloting or evaluating document imaging, EPR and related technologies. There simply aren't many other ways to wring out inefficiencies, improve management control and reporting systems, and utilize the knowledge of employees that can make as much gain in productivity as KM technologies.
The technologies comprising KM as a whole include database technology, document imaging (electronic copies of paper documents scanned into a networked computer system), workflow (automating the flow of work, typically patient or financial folders), COLD (computer output to laserdisk, a replacement for archiving reports on microfiche which allows for report data mining), forms processing (electronically extracting key data from forms) and document management systems (which track versions, user access and renditions of electronically created documents, such as spreadsheets and word processing files). This entire complementary technology set has been referred to recently as Knowledge Management tools.
The advantage that early adopters of imaging, workflow and EPR systems have is beginning to melt away as the proliferation of these systems continues. Demand has accelerated greatly. Companies that sold a half-dozen of these systems in all of 1996, are selling the same numbers of systems (or more) in a fiscal quarter in 1997. While leaders in the banking and insurance industries--even the Federal government--were piloting similar (imaging/workflow) systems more than a decade ago, it is obvious to market observers that these systems have now gone from concept to actual implementation projects. We are not moving toward an electronic patient record--we have it, and it can provide a huge advantage.
The advantages of such EPR systems and related KM technologies go far beyond the typical tactical reasons that often justify these systems. Yes, there will be labor and space savings, and, yes, patient folders will never again have to be re-filed. What is more important is that EPR systems can improve care by providing accurate information more quickly to the caregiver. As much as 40% of the time, some surveys suggest, the caregiver makes decisions without a patient record, or based on incomplete information at hand. This, by definition, means that care is being compromised. Therefore, providing the best available information at the right time can improve care, reduce labor costs and potentially even the length of stay by fractions of a day or days. In an era of capitation, this benefit goes straight to the bottom line. This is talk that lets CEOs, CFOs, administrators and senior managers know where the return is on these rather large investments in IT. Better care at a lower cost? It is music to their ears. That is not to say that completing an imaging/workflow or EPR project is a small undertaking. It takes top down commitment and a team approach. It is a long grind, but the payoffs have proven to be there.
Then, there is the added benefit of reduced exposure to risk. This is a significant benefit in our litigious society. With awards commonly in the millions, one lost lawsuit easily justifies the purchase of systems that can track and maintain accurate documentation.
How can EPR or KM systems reduce liability? Think of the regular outpatient that comes into the ER. Think of the potential for misdiagnosis or lack of proper treatment without the patient record being available immediately. Think of the benefit to the patient, the caregiver and your organization. It then becomes clear that risk reduction can be a goal of implementing these systems.
A common mistake that healthcare concerns make in beginning projects of this type is to focus on the most important immediate needÑperhaps in the business office, ER or HIM. The sponsor for the project may have a key area to focus on for various professional, political or personal reasons. This area then becomes the central point for the evaluation of systems. What often is missing is the enterprise-wide view. Healthcare organizations have a history of allowing departments a great deal of autonomy. This resulted in the short-term satisfaction of departmental needs, but created long term problems for the IT infrastructure of the organization. Basically, System A will not communicate with System B. For instance, can an employee's Human Resource file electronically include the appropriate information from his medical record of a recent inpatient stay or outpatient visit, if needed?
The development of sophisticated data interface engines and standards like HL7, DMA and ODMA have partially mitigated this problem. Someone in the organization needs to represent the long-term view. It is a view wherein patient folders (including radiology images/MRIs and possibly video, in the future), electronic reports, word processing documents, spreadsheets and any other type of "document" needs to be securely accessable by those that need it, in a timely fashion. The systems, which provide this information, must be able to interoperate. This is the challenge of the modern manager in healthcare, and it is no small task.
Robert F. Smallwood is a partner with IMERGE Consulting and leads the Healthcare Technology Partners Practice. He can be reached at 504-525-4500, bob@imergeconsult.com.