Document imaging a welcome site for MUSC
Today's medical record archive fills file shelves, filing areas and warehouses. Handwritten orders, paper progress notes, nursing notes, problem lists and advance directives—it could be more. This mountain is the 85 percent still on paper. The rest is electronic—less than one-fifth, but growing. Bridging the gap from paper to entering patient medical records directly into MUSC's electronic medical record system, called Emerald, is the newcomer in the electronic medical record rollout—document imaging. Implemented Oct. 11, document imaging creates electronic images of the paper forms and allows any number of staff members to access paper information once available to only one person at a time. This facilitates not only improved information flow for patient care, but also opens opportunities for improved efficiency in critical business processes such as electronic signatures, chart completion, and the release of information. Document imaging works by creating digitized images of the paper forms as they are fed through a high-speed scanner. As the documents are scanned, bar codes identify both the patient and the forms so that the information can be properly filed and indexed. The result is an indexed picture of the paper in electronic form, which is then viewed by an Oacis workstation. Through the use of this technology, thousands of pieces of paper can be stored on an optical disc or CD, requiring only a fraction of the storage space. Using a process called image enabling, staff will not only be able to access the discrete clinical data normally associated with Oacis, but also the images of the paper documents. The simultaneous access of both data types, using the familiar Oacis roster paradigm, will more readily provide a more complete picture of a patient than is possible at the present. Processes on paper such as coding and abstracting, deficiency analysis, chart completion, and release of information traditionally have been sequential in nature and have involved the transportation of paper from step to step. There are many opportunities to misplace documents or even the entire record as the paper moves from coder to analyst, analyst to physician, physician to physician, and so on. With document imaging, the simultaneous document access to the record allows staff to abstract the visit, analysts to identify and assign deficiencies, coders to assign codes for billing and statistics, and physicians to complete deficiencies and sign documents, all from their desktop workstations. Medical record security will be enhanced by the new system. In image form, medical record security and access is controlled through individual passwords. Electronic signatures on documents will also be password protected. Regularly monitored system access log files will provide an audit trail showing access to medical records. Before a record is scanned, an encounter sheet with a bar-coded medical record and patient communication number is produced. This document identifies for the system the patient to whom the following documents belong. Following the encounter sheet, the bar-coded forms are scanned and automatically assigned indexes. It is expected that this efficient process will dramatically expedite the filing of records as well as reducing the opportunity for misfiled records and documents. The quality of images in the new system is also a top priority. Health Information Services will be trained in the use of the imaging tools to ensure the images are of the highest possible quality. At the document imaging system kick-off, much progress has already been made. The essential, but time-consuming, process of adding bar codes to all the medical record forms is well under way. The activation of the electronic fields and the image enabled Oacis
are processes that are well in hand. Training of Health Information Services
personnel to use the equipment will begin to intensify. Pilot personnel
(Holling Cancer Center) will begin their interaction with the technology
as the system is thoroughly tested.
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