Why Re-Digitize? A Transformation to an Actual Paperless System

I’m pretty sure that most of you reading this can relate to watching TV or listening to the radio and being bombarded with the exorbitant amount of commercials out there for various insurance companies. Most claim they can save us money (in 15 minutes or less) or that they offer benefits far better than their competitors. Recently I saw one that caught my attention. It starred a walking, talking, dancing box that sang a catchy tune to promote “going paperless”. Unfortunately for the insurance company, it didn’t convince me to immediately grab my phone and call in to switch providers, but the commercial did succeed in making me really think about what it means to go paperless in our technology-driven world. Thinking about that got my wheels turning on how the paperless concept should be applied throughout the many different layers of healthcare.

Even though we’ve seen incredible growth in the use of technology in healthcare, it continues to rank among the top of the list when it comes to industries that still use good ol’ fashioned paper. The banking industry offers completely paperless banking through emailed customer statements, deposits using the camera on your phone, or transferring money directly from an app. Luckily, they haven’t yet done away with paper cash! The auto industry has not only become paperless by allowing you to apply for financing online, now you can even buy a car and e-sign the paperwork without leaving your house. I’ve come across a number of stores who will ask you if you’d like your receipt emailed to you in lieu of handing you a paper receipt at the cash register.

With all the hype around going paperless, it’s important to analyze what that truly means for a hospital and the healthcare industry as a whole. As we are all aware by now, hospitals are investing a tremendous amount of time, resources, and money into the implementation of an electronic medical record (EMR) with the ultimate goal of improving patient care and outcomes. The process of implementing an electronic medical record system is a very arduous process, to say the least. Most people believe it starts with vendor selections or budgeting. I’ve spoken with many hospital executives on this topic and they’ve told me the process actually begins with evaluating the existing IT infrastructure and clinical workflow. This means a hospital has to ask themselves several important questions, with three of the most important being, “What do we currently have?”, “What are our goals?”, and “What are our specific needs to accomplish those goals moving forward?” After there are concrete answers to these questions, it is time to develop a clear plan for making it happen.
As a hospital evaluates their current environment, they have to decide how to address the existing paper workflows. They need to consider each process that is utilizing paper and assign it to 1 of the 3 categories below:

• Convert the current paper workflow into a fully electronic workflow
• Accept that it will be unable to go paperless at all
• Develop a process that initially uses paper, but is converted to a digital format later

Most hospitals know that when they implement an EMR, it will include making decisions on computerized order entry, clinical documentation, a laboratory system, a pharmacy system (including eMAR), etc… Based on advice from their vendor of choice or a hired consultant, these decisions are fairly easy to make and convert each of these to being completely paperless. On the opposite end of the spectrum, there will be specific workflows that they’ll be unable to convert to paperless, based on the current technology available. A very simple example of this would be the printing of a patient’s ID band because that is still the most reliable way to perform a positive patient ID. The most difficult scenarios for evaluation fall into the third category. There are some workflows that originate on paper that can be converted to an electronic format by scanning. For example, consent forms are printed on paper, the patient physically signs the forms, and eventually someone in the medical records department will scan them in to attach to that patient’s permanent medical record. In this scenario scanning makes sense because the process starts with a piece of paper, however there are many other instances where scanning documents into the patient’s medical record is not the optimal solution for going paperless.

I recently completed a clinical information system optimization case study at a world-renowned academic medical center who had just completed phase 1 of implementing their new EMR. After everyone had taken a deep breath (and probably a couple of weeks of vacation to decompress), they started to evaluate ways to fully optimize the infrastructure they had just put in place. Specifically, they were looking at workflows within the hospital that begin in digital format, are then converted to analog format by printing it out, and ultimately converted back to digital format through scanning to be entered into the patient’s electronic record. They wanted to see which of these workflows could be restructured into being fully digital. The most obvious scenario where this was occurring in their hospital was related to clinical documentation for the physiological monitors. The majority of hospitals have either implemented, or have plans to implement, a middleware solution for electronically capturing medical device vital sign data that enables them to periodically send the information to the clinical flowsheet. Unfortunately, this solution does not address the capturing of cardiac strips from the patient monitors. In order to capture this data, a hospital must go through several steps; identifying a cardiac event, print out the associated cardiac strips, cut and paste them onto an 8.5 x 11 inch piece of paper, running or tubing the strips to the unit, place the paper strips into the patient’s paper binder, and eventually scan the paper strips into the patient’s electronic record some time after discharge. For purposes of describing this process here, I have way over-simplified what is actually necessary for every patient and every event that takes place throughout the course of a patient’s hospital stay. When hospitals are asked the obvious question of why they’re doing this, the most common response is that they didn’t know there was any other way. It definitely doesn’t make sense to continue such a time-consuming process if a fully digital solution exists. Since the data is originally captured digitally, there should be a way of adding measurements by using on-line calipers, making comments on the strip, and transmitting these cardiac strips to the patient’s record electronically. This enables the hospital to completely avoid printing and scanning the strips post-discharge.

The particular health system that I previously mentioned in regards to the completed case study has decided to implement Excel Medical’s Next Generation Medical Device Integration Solution. This solution will capture the information generated digitally from the physiological patient monitors and allow clinicians to create a cardiac report that includes both the waveforms, and documentation. Once that report is generated, it can be sent electronically to the EMR, thus eliminating the need for printing and scanning. The goal is for the health system to positively impact patient care and outcomes by replacing the time-consuming and costly process currently in place. They will be measuring and reporting that time and cost savings, delivering current and accurate information to the bedside clinicians, reducing documentation errors or non-compliance, decreasing risk exposure, and positively impacting quality management scores and liabilities. I have had the opportunity to be involved in several meetings at this health system and the issue has been officially labeled (internally) as “Why Re-Digitize?” This truly is the perfect name for improving an outdated and broken manual process.