Paperless Health Record File Room Phyllis Sullivan, RHIA Chief, Business Management Service, Birmingham, AL Sean L

1. 1 Paperless Health RecordFile Room Phyllis Sullivan, RHIA – Chief, Business Management Service, Birmingham, ALSean LongoskyAssistant Chief, Health Information Management, Puget Sound Healthcare System

2. 2 Approaches Off-Site Storage - NARA approved facility for active hard copy records that cannot be retired. Process to computerize all documents. Scanning Medical Record – Each document scanned into VistA Imaging

3. 3 Off-Site Storage 

4. 4 Organizational Support Medical Record Committee Health Systems Committee Director and Chief of Staff Support Space Constraints FTE efficiency Privacy Patient Care IT Support Union

5. 5 Stage the Process 1. Conduct Research for the Project 2. Organize a Team 3. Review Documentation Needs 4. Review HIM Personnel Needs 5. Review IT Needs 6. Contact Record Storage facility 7. Communication to Clinical Staff and End Users 8. Training

6. 6 Research Assess the organization’s readiness for paperless file room (computerization of essential documents for patient care). Be sure to include CBOC analysis Conduct a facility wide and CBOC walk through for loose filing Volume of records to be stored Volume of hard copy documents to be computerized Frequency of record retrieval Proficiency of Clinical Staff in use of VistA Imaging Visit the records storage site Estimate the supply costs-boxes, tape, shrink wrap etc. Utilize the VA references

7. 7 References Federal Record Center Toolkit Closing File Room FAQ NARA web site VHA Handbook 1907.01

8. 8 Organize the Team Health Information CAC/CPRS Nursing Clinical Staff IT/VistA Imaging

9. 9 Paper Documentation and Forms Each paper document received in the file room should be reviewed. Determine if document/form is needed as part of the permanent record Quality Resources reviewed for Joint Commission requirement Service involvement in determining valid need Develop a working list of paper documents to include Medical and Administrative folder Is there a template in place? Should a template be created? Determine if document can be entered into CPRS or scanned into VistA Imaging, (ex. ICU use of tri-folds that could not be scanned)

10. 10 Converting Paper to Electronic Identify clinical services using paper forms Review paper forms to be computerized Clinical service input on template development Templates to be approved through Medical Record Committee prior to use Host weekly meetings with clinical staff and CPRS to provide status of template development and finalization. Patient care forms are very time consuming to convert from paper to template Developed the procedure to pick up documents for patients in the hospital (daily, weekly, after discharge)

11. 11 Community Based Outpatient Clinics Meet with the program manager Physically go to the clinics to assess the volume and shape records are in (physically had to merge the Primary Care with Mental Health records) Develop approach for retirement/off site storage. Director and program manager approved approach Created a core team which included file room, CBOC, Security and Logistics Worked weekends/week day afternoon Records brought to Birmingham facility to process by former file room staff Processed through the record retirement process

12. 12 HIM Personnel Needs With increase of scanning volume, HIM Scanning personnel needs must be assessed Determine the amount of paper to be scanned to establish needed FTEE Conversion of File Room FTEE to Scanning FTEE A recommended simple formula to assist in computing FTEE is: The average amount of paper scanned per hour per FTE.

13. 13 Review IT Needs # of I-Med consent e-pads # of computers needed by clinical staff # of additional scanners # of Voice Recognition licenses

14. 14 Federal Records Center FRC has temporarily stopped accepting records shipments, except for those facilities that already have accession numbers for inactive records. Active records (less then three years) will not be accepted at FRC. These records must be stored at a NARA certified record center. Obtain permission from the Records Center and Vault to retire records by contacting: Kim Tuggle, Supv Archives Specialist (417) 451-4967

15. 15 Paper Record Storage Communicate with Logistics for shipping/storage of records to be retired (secure storage) Contract developed for record storage and retrieval Storage must be NARA certified NARA certified facilities are found at: http://www.archives.gov/records-mgmt/basics/central-registry.html NARA approval and inspection requirements can be found at: http://www.archives.gov/about/regulations/part-1228/k.html

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18. 18 Communication Clinical staff must be kept informed Health Systems Committee Directors Staff meeting Postmasters Target Vision Clinical service staff meetings Ensure clinical staff understands the procedure for record retrieval Designate a firm date to implement the paperless file room

19. 19 Training New Templates Voice Recognition VistA Imaging Record Retrieval process

20. 20 Scanning Medical Records into VistA Imaging

21. 21 HIM Business Processes Record creation Record storage and retention Filing: loose reports, the records Record delivery & pickup Transcription Coding Release of information Data collection, analysis & MR review Confidentiality, privacy & security Forms Management Other

22. 22 The Hybrid Environment Where do business processes occur? Where is the file room? Record delivery – How long? Importance of Policies Printing? When do you stop? Who is authorized to ‘write’ in the record? bylaws

23. 23 The Hybrid Environment, Cont’d What technologies are used to document care Handwriting; how entered into the EHR? Dictation/Transcription Direct entry by clinician Photographs Interfaces from machines Copying and Pasting Many issues! Worth the risk?

24. 24 HIM Staffing – Files Unit Staffing: Downsized from 30 to 13 employees in a 3 year period, now hiring 6 additional FTEE Scanning issues Indexing Point of care vs. centralized Scanning/Imaging In HIMS Audiology & Anesthesia

25. 25 Release of Information (ROI) Turn around time Usually same day Delays Doctors’ signatures on forms Requests for archived records Request for multiple volumes of records Staffing From 3 to 2 FTE’s at each site (Seattle and American Lake) for coverage

26. 26 Management Changes Staffing 1998 4 managers and 1 specialist 2004 5 managers and 3 specialists 2007 6 managers and 5 specialists New competencies required in: Scanning Electronic data Data management/reporting

27. 27 Management Changes, cont. Expanding roles Privacy Monitoring CPT/professional services coding Other concerns Policy generation Be seen/Get to the table Systems thinking

28. 28 Emerging Issues Template management Title management Maintaining electronic documents Completion and authentication Controlling printing Staff competencies Others?

29. 29 Taming the File Breathing Dragon

30. 30 Filing Backlog Become a detective and find how much loose filing there is. It is not just in the file room. How much is there and where is it all stored. Must clean up the filing backlog to proceed with retirement. Neosho is NOT a giant file room, it is a records retirement center.

31. 31 Retirement List After the filing is caught up, generate a pull list using the VistA menu Pull records Pull documents for scanning that are: Not in CPRS but may be needed for care or by the veteran I went to each Service and asked what they might need out of the records. I was surprised that they really did not want that much pulled.I went to each Service and asked what they might need out of the records. I was surprised that they really did not want that much pulled.

32. 32 Document Pull List Pull documents from chart. Sort in labeled boxes for scanning. Administrative Documents - Small list but important to veterans. DD214 - Make sure the Social Security Number is on the document Rating Decision Letters

33. 33 Clinical Documents “WET” signed Discharge Summaries, GI – studies such as EGD, Colonoscopies Cardiology – Cardiac Caths, Stress test if not in Muse or Nuclear Medicine. Surgery – “wet signed” Operation Reports, and Pathology if not in CPRS Anesthesia flow sheet Audiology – audiograms Compensation & Pension exams Don’t groan but ALL eye notes and eye tests. Other?

34. 34 Meanwhile, Back at the Ranch While you staff is retiring records check new incoming documents for: Is it an authorized form? What kind of documents are you getting and from where? Outside records – by policy? Remember once you start retiring records you will have to scan what comes down. You will find that with the advent of the computer many departments make up their own forms without going through the proper channels of getting it approved. In most cases the form could be completed in the computer. Finding that nursing service is one of the biggest form creator.You will find that with the advent of the computer many departments make up their own forms without going through the proper channels of getting it approved. In most cases the form could be completed in the computer. Finding that nursing service is one of the biggest form creator.

35. 35 The CAC and You You should have a good working relationship with your CAC. They can Be the go between services and HIMS Pave the way for generation of templates to stop paper documentation Explain to services computer solutions to their particular documentation dilemma

36. 36 Scanning Scan only documents that can not be entered directly into CPRS. Scan new documents first then the Eye clinic documents Then “boxed” up medical documents from your retirement pull Finally scan the administrative documents This has been said many times but it bears repeating. Scan ONLY documents that can NOT be entered directly into CPRSThis has been said many times but it bears repeating. Scan ONLY documents that can NOT be entered directly into CPRS

37. 37 Eye, Eye Sir Decision is made to not send records to the Eye Clinic. How do you proceed? Print up a pull list 3-4 days out from the clinic date Pull all eye documents, index and scan them Stamp record front bottom right with scanned stamp and write in eye. If you stamp the bottom right side of the chart your clerks will not have to pull the record off the shelf to see if it has been scanned. This will speed up the processing of the records. You can use this same process as the decision is made not to send records to clinics.If you stamp the bottom right side of the chart your clerks will not have to pull the record off the shelf to see if it has been scanned. This will speed up the processing of the records. You can use this same process as the decision is made not to send records to clinics.

38. 38 EYE SCANNING Scanning notes Place in date order with newest note on top In Image description type in the date range Scanning tests Scan each “type” of test separately Place in same test type in date order with newest on top. Index using procedure event indexing and in image description type in date range. Scanning eye documentation is a huge undertaking due to the amount of documentation and the indexing involved. At first your staff will be overwhelmed and upset but this will pass once they see that they can do what is asked. All your staff will have to scan eye documents at first. It is best that each one specialize on a document type. One or two do notes, another visual fields and so on. The largest amount of eye scanning will be from your glaucoma clinic since they are frequent eye clinic visitors. Over time the amount of eye scanning you will have to do will drop. Scanning eye documentation is a huge undertaking due to the amount of documentation and the indexing involved. At first your staff will be overwhelmed and upset but this will pass once they see that they can do what is asked. All your staff will have to scan eye documents at first. It is best that each one specialize on a document type. One or two do notes, another visual fields and so on. The largest amount of eye scanning will be from your glaucoma clinic since they are frequent eye clinic visitors. Over time the amount of eye scanning you will have to do will drop. Scanning eye documentation is a huge undertaking due to the amount of documentation and the indexing involved. At first your staff will be overwhelmed and upset but this will pass once they see that they can do what is asked. All your staff will have to scan eye documents at first. It is best that each one specialize on a document type. One or two do notes, another visual fields and so on. The largest amount of eye scanning will be from your glaucoma clinic since they are frequent eye clinic visitors. Over time the amount of eye scanning you will have to do will drop. Scanning eye documentation is a huge undertaking due to the amount of documentation and the indexing involved. At first your staff will be overwhelmed and upset but this will pass once they see that they can do what is asked. All your staff will have to scan eye documents at first. It is best that each one specialize on a document type. One or two do notes, another visual fields and so on. The largest amount of eye scanning will be from your glaucoma clinic since they are frequent eye clinic visitors. Over time the amount of eye scanning you will have to do will drop.

39. 39 Process, Part 1 File ALL loose filing must be done before the next step Retire all records for veterans not seen in last 3 years. Generate a list with last date seen 2 ½ years ago since it will take at least 6 months to get the charts to Neosho Retire all death records Pick a clinic to see if they could stop receiving records Mental health best starting point since they extensively use CPRS

40. 40 Process, Part 2 Talk to the clinician NOT the clerk Left Eye clinic as the last clinic to ask since they use notes (drawings) and tests that can’t load into CPRS Work with your CAC’s Work out scanning process NOT a filing process. Keep looking at documents that could be computerized Found that the clerks have a vested interest in getting records…It makes them look so busy. If you talk to the clerk they will say my clinicians need the record. The clinician on the other hand will tell you oh no they don’t need records. We set up a telephone number that the clerk could call if the clinician needed a record and we assured the clinician that we would deliver within 10 minutes. With this assurance the clinics said no to the record pulls. When we tackled EYE it was a two pronged approach. The CAC’s developed templates and I and the Eye Clinicians developed a scanning plan that met the needs of the clinicians.Found that the clerks have a vested interest in getting records…It makes them look so busy. If you talk to the clerk they will say my clinicians need the record. The clinician on the other hand will tell you oh no they don’t need records. We set up a telephone number that the clerk could call if the clinician needed a record and we assured the clinician that we would deliver within 10 minutes. With this assurance the clinics said no to the record pulls. When we tackled EYE it was a two pronged approach. The CAC’s developed templates and I and the Eye Clinicians developed a scanning plan that met the needs of the clinicians.

41. 41 References Federal Record Center Toolkit Closing File Room FAQ NARA web site VHA Handbook 1907.01 Thank You! Questions?