Products & Technology

Downsized Documentation

How providers can utilize document imaging and management systems to cut costly inefficiencies while sharpening their strategic edge.

• By David Kopf
• Apr 01, 2010

Trees hate the healthcare industry. As HME providers well know, the amount of documentation required to serve patients is so deep that they are often swimming in paperwork. Every piece of paper, every signature, every attachment represents a key step in the process of caring for a patient and ensuring that the provider collects funding for its services. No paperclip or fax transmission is without worth.

But for the importance placed on proper documentation, handling the process via paper in an age when people use computers to buy and read entire books seems both an anachronism and a terribly inefficient way to handle the process. And in a brutal funding environment with razor-thin margins, inefficiency is verboten at HME businesses. Cutting costs reigns supreme.

That is exactly why document imaging and management systems are getting increased attention from HME providers. Document management systems let providers scan in paper documents via fax machines and easy-to-use sheet-fed scanners (as opposed to flat-bed scanners), and then let staff more efficiently access, update, share and manage those documents both internally and with other healthcare professionals involved in a patient’s care.

“The main value proposition is increased efficiency,” says Esther Apter, the president and CEO of MedFORCE Technologies Inc., which provides paperless documentation systems to the HME industry. “But that is part of the whole move toward process management and LEAN functionality. In other words, there is a lot of time wasted dealing with paper documents. Regardless of whether you’re retrieving papers from filing cabinets or if they’re being handed off from one desk to another, there is a lot of time wasted during those kinds of functions.

“Basically, the idea is: let’s say you have a 25 percent profit margin,” she continues. “If you make an extra 100 dollars then you’re going to drop 25 dollars to your bottom line. But if you save 100 dollars you drop that entire 100 dollars to your bottom line. Those kinds of savings, especially in our environment, is critical.”

A Strategic Necessity

While many providers might initially consider document imaging and management a sort of reactionary response to the dilemma of drowning in paper, many providers elect to implement such systems to give their businesses a strategic edge and a firm foundation for growth. Such is the case for Asheville, N.C.-headquartered Aeroflow Healthcare Inc., an HME with multiple locations providing diagnostic testing for sleep patients, home respiratory, and rehab mobility in North Carolina and Tennessee.

Besides the fact that, Aeroflow provides services that are clearly laden with deep documentation requirements, but a paperless system didn’t just offer a “fix” for the provider — it offered possibility, says Casey Hite, vice president of Aeroflow.

Prior to implementing a paperless solution from MedFORCE Technologies, Aeroflow only had two locations, but those two locations generated enough paper documentation that it was obvious a document imaging and document management solution was a must-have. But, what really prompted Aeroflow to seek a document imaging and management system was its strategic objective to expand its business into new services areas, Hite says.

“Our model has always been that, in order to grow quickly and be efficient, every time we want to open a new Aeroflow location, we do not want to open it as though it was a ‘green field’ operation,” he explains. “We run all data, phone calls, faxes, and really everything through our corporate office through a local phone number that is forwarded.

“So with these offices that we opened up, our initial reason for looking at document imaging was that, since we are running all this information through our corporate office as a hub, these patient charts and documents needed to be at the corporate office,” Hite continues. “So that [document management] has certainly allowed us to grow and really operate as if we are one office spread over several states.”

Without that paperless technology, Aeroflow couldn’t be set up that way, according to Hite. All of Aeroflow’s employees in its various locations work off of its main, centralized servers located in its Asheville headquarters.

“Everybody is working off a shared database and shared ‘everything,’ and no matter how far away somebody is, they’re in the same virtual office,” he explains. “The primary benefit of taking your company paperless is that multiple people can access the same documents and not have to search files, and being able to communicate with people without the minutiae of paperwork.”

Other Benefits

That centralized aspect of document management also adds instant accountability for both staff and external parties since the tracking capabilities of paperless systems make clear who touched which part of a document, how and when. “Everybody’s desk is wide open, everybody’s office is wide open, your drawers are open; nothing’s being hidden or being misplaced,” he says.

Because the system is tracking the documents, Hite says it actually enhances a providers’ HIPAA compliance by monitoring documents every time they leave the system (say to go to a referral partner) the system queries users why the document is leaving the system and to whom it is being transmitted, further safeguarding patient data. Also, certain portions of charts or folders of documents can be blocked from being changed by certain employees, or even being viewed by some staffers.

“At our company, we separate the documents that non-billing people are supposed to see from the documents that billing people are supposed to see,” Hite says. “For instance, sales people can’t see sensitive documents or documents that could be sorted incorrectly or misplaced. So you can really get granular with the security rights so that people only see what they need to see.”

Treating documents as electronic files, also affords a level of control far above that of paper file management. Providers can flexibility add whatever context is required. Charts can be reorganized and redistributed at one time. A subfolder in a patient’s chart can be moved to a different part of the chart, or the same change can be made globally with a whole set of charts all at one time.

Document management also puts a stop to paper chases. Since every piece of documentation arriving at Aeroflow comes in via an incoming fax server (faxes constitute the lion’s share of Aeroflow’s imaging), and imported into MedFORCE, there is no way for documents to get lost.

“Documents are never actually handed to any individual,” Hite says. “Everything is handed to them in electronic format, so that nothing can get misplaced. Once it’s in, there’s no way to loose it, and there are ‘footprints’ to follow it throughout our procedures.”

Also, easy document retrieval also enhances accreditation and audits, since finding the correct documentation during site visits is always a mouseclick away, Hite and Apter note. “The documentation is right at [providers’] fingertips,” Hite says. “You can present a much more organized patient chart.”

“There are certain documents that you need to have on file, and to go through and audit every single file to make sure you have those documents is virtually impossible,” Apter says. “A document management system should be able to provide you with an analysis as to which documents you might be missing, and that’s something you really can’t do with paper.”

And, as the medical community moves closer to electronic patient records and other electronic record keeping, document management could someday be more of a requirement to accreditation, she adds.

Working with Referral Partners

While there are many initiatives to implement electronic patient records in the hospital industry, the main way that physicians offices and other referral partners interface with HME providers remains the trusty fax machine. While almost relics in the Internet and wireless age, faxes provide a simple means to almost instantly image and transmit documents between referral partners and HMEs, says Ed Bauer of Noble House, which makes Noble Direct an HME management software system that includes document imaging and management.

“At this time, there’s been talk and efforts at implementing electronic medical records,” Bauer says. “Few physician’s are using those technologies at this time. But the accepted method of communicating is still fax. If I had to guess I would guess that 80 to 90 percent of physicians offices are still faxing.”

“The main way we have been able to create efficiencies for outgoing paperwork, say to obtain a physician’s signature, is that everything we fax actually never hits paper in our office,” Aeroflow’s Hite says. “So a document is created via a form and faxed directly out of MedFORCE to the physician, and when that fax comes back, it still comes back electronically. It’s a lot more efficient for people to generate faxes from their desks, rather than getting up and walking to a fax machine.”

To add further efficiency, when the fax forms are generated and transmitted to referral partners, they include bar codes. This means that when a referral partner updates and returns the paperwork, Aeroflow’s system scans the barcode and automatically attaches the paperwork to the correct patient records and documentation.

Selecting, Implementing a Document Management System

For providers that are scrutinizing document imaging and management solutions, Hite says that the key is to look not at the systems themselves, but rather how they as a business address their processes internally. He says too many providers still process hard copy paperwork and don’t image documents until the end of the process; only to update the patient chart. “A lot of providers look at document imaging as a way to electronically replace filing cabinets,” he says.

“If you look at a document imaging system solely to do that, but don’t change any of your internal processes to capitalized on the benefits of a document imaging solution, you’re not going to benefit much at all.

“Yes, you’ve saved room, and multiple people can access a document,” he continues. “But if you’re still handling paper via fax or delivery tickets or completed CMNs, and then you’re handing that document to the employee that handles those documents, and they hand it to the next person in line and so on, and then, at the very end, when patient has been billed, you are electronically filing it, then you really haven’t benefit anyone in you’re account receivable/collections department. You’ve missed the front end with customer service and sales people, etc. None of them benefited from it. I think most companies still operate in that fashion.”

A document management system should be able to mimic a provider’s workflow, MedFORCE’s Apter says. “If you have a certain flow, and the system can mimic that, then you’re going to be able to improve on it easily,” she says.

Ease of retrieval is key, so providers will want to look at are the document indexing capabilities of a system. The system should provide tools for automatically indexing incoming documents based on the forms or barcoding so that provider staff doesn’t have to manually “slot” each incoming piece of paperwork, Noble House’s Bauer says.

“Our program will scan each document as an image file and then index each document in the proper patient record based on that barcode,” he says.

“The barcode becomes part of the document,” says Richard Mehan, president and owner of Noble House. “That is the identifier that tells us which document it is and who it belongs to.”

Then, when provider staff members are accessing documents in the Noble House system the information can be located via the likely avenues. For instance, if a staff member is seeking patient documentation, he or she would go to the patient’s record in Noble Direct and click on a document-imaging icon to see thumbnail images of all the documents related to that patient, Bauer says.

“Then those documents can be brought to the screen, expanded and printed,” he says. “Or they can be moved to other locations, or things like that. All the documents are integrated into the program’s database. There are no other programs that have to be opened.”

And of course, a document management system should have decent manual indexing controls, as well.

“A lot of documents that come in can’t be automatically indexed,” Apter says. “Let’s say they are a prescription written by the doctor or a maybe it’s progress note written by a therapist, those kinds of documents have to be filed as well. You have to manually decide where they go. The fewer clicks and the less typing you have to do the more efficient you will be when filing a document.”

In terms of inputting documents, a document management system should be able to input large, multi-page documents with various attachments, such as a sleep study for example, as a single file into the system,

And once the documents are accessed, users should be able to quickly page through them without any lag time. The experience should at the very least be as fast as paging through a paper file.

There are potential “process pitfalls” providers will want to look out for, when implementing a paperless system. Hite advised HMEs implementing document imaging and management systems to have one point of data entry, so that incoming documents only go through one channel.

“For instance, if you have one person monitoring a fax machine or taking verbal orders, then that is the one person that is scanning and sorting incoming documents,” he says. “That’s critical, because if you have multiple people putting multiple documents in multiple charts, there is a lack of accountability, and the potential for documents to get misplaced.”

Another key thing for providers to watch is that their document system should integrate very well with their billing software in the same way they want to make sure the document management integrates with their workflow. Document management, HME billing/management software and process should all play the same tune in terms of process. And, many HME software solutions, such as MedFORCE’s WorkFLOW and D&R manager and Noble House’s Noble Direct, provide this integration.

“You want to make sure that the two work together very well so that you’re not doing double data entry,” Hite says. “You don’t want to enter data into the billing system and then enter it again in the document imaging solution. You want to the two to integrate seamlessly so that the two applications communicate with each other.”

“We’ve been able to take advantage of designing our document management directly into our billing software to gain the ability to automatically store any documents that our software generates,” Noble House’s Mehan says. “For example, when we print patient invoices, simultaneous to printing it we are also storing the image and attaching it to the patient.”

Interestingly concern that might initially seem large, but winds up being a lesser issue is training, Noble House’s Mehan says. The reason for this is that a good system and successful implementation should wind up being easy for staffers to use.

“I think they’re very intuitive,” he says. “I think the most difficult part of document imaging is from the technical side; getting the equipment functioning. Once the hardware is installed, everything else is easy.”

Similarly, storage isn’t necessarily a big issue. Because memory has gotten so cheap, and because the scanned document footprints aren’t large, the server “iron” required is not as massive as one might initially expect. Moreover, if the document imaging and management system is part of a hosted HME management system, the servers would be hosted at the software provider’s location anyway.

So the provider is essentially uploading a document after it is imaged and then accessing the document through the software. This might be a little slower, but it also provides the additional benefit of having its data stored on the software company’s backup servers, which are usually implemented with a serious eye on fault tolerance and reliability.

“I’d recommend that option to any company that doesn’t have a good IT infrastructure,” Hite says.

This article originally appeared in the April 2010 issue of HME Business.