Saturday, February 23, 2008

Scanning Technologies

One of the great things about writing a blog is that I can share my experiences so that other CIOs can avoid mistakes I've made. Over the past 5 years, I'm made several mistakes - not understanding network technology enough to prevent our 2002 network outage, underestimating the popularity of voice recognition dictation systems, and believing that users would migrate to our new intranet site purely based on the advanced technology we implemented. One area where I need to formally state I was wrong is scanning technologies. I have never liked scanned images of medical records. They are not interoperable, they are challenging to store, and they are difficult to navigate because they are not searchable. However, I have recently found a few use cases for scanning technology that have proven me wrong.

1. Inpatient records
Although BIDMC's outpatient records are entirely electronic, our inpatient progress notes, nursing notes,and Input/Output records are still paper-based. In 2008, we're creating electronic History and Physicals that will serve as the foundation for future work on inpatient clinical documentation, but in the meantime we need to make our paper records available electronically for several reasons. Hiring and retaining medical record coders is challenging in the Boston area. If we can make scans of our inpatient records available electronically via a secure web-application, we can hire medical record coders anywhere in the country. Additionally, real estate in the Longwood Medical Area of Boston is very expensive. Storing paper records nearby is just too expensive, so we built a storage facility in Dedham 15 miles away. Retrieving a chart from the storage facility can take a few hours. Having an electronic version of paper records saves time, storage space and energy.

2. Doctor's doodles, outside labs and lab requisitions
In some clinics, doctors make drawings of skin lesions and physical exam findings. Our ambulatory medical record does not include real time graphical input via Wacom tablets or other electronic drawing devices. Hence we need some way to include these doodles as part of the electronic record. Creating a drawing, then bar coding it, makes automated scanning into the right patient's record possible. Also, every day we receive 15 inches of paper from referring clinicians and outside providers. Today, that's all filed in a paper chart. Scanning paper received from outside providers and making it available within our ambulatory record ensures continuity of care. Finally, we receive paper-based lab requisitions from clinicians who want to order BIDMC labs but are not using our electronic health records or provider order entry system. Although we do not consider these requisitions part of the medical record, the lab needs to retain them as proof that the specified tests were performed on the basis of a signed order. Scanning them eliminates the need to store paper and makes retrieving them for audits much easier.

3. Consent workflow
Although we've experimented with automating the consent process, we've found that most consents are done in private clinician offices where we have no control of the technology or workflow. By scanning these paper consents into the record and making them available as part of peri-anesthesia testing, we ensure that all documentation necessary for a successful surgery is available before the patient arrives at the Operating Room.

We're now live with scanning our lab requisitions and inpatient records. We will soon go live with scanning doctor's drawings and outside labs. Consent scanning is planned for next year. The technology we use includes Fujitsu high speed scanners and Captiva image capture software. Our Health Information Management professionals scan any written documentation in the paper record and generate a PDF for each tab in the record, making the electronic version easy to navigate. We've created an automated link to a web-based viewer (screen shot above) that associates the scanned records with the right patient based on a bar code included on the first page of each scan that is optically recognized by Captiva. We've made these scans available to our medical record coders working at home. Homesourcing saves time, reduces real estate costs, and enhances productivity. It's a win/win.

Thus, scanning technology with automated creation of PDFs and web-based viewing organized by document type does work very well during the transition from paper to natively electronic workflows. I stand corrected.


-= MT =- said...

Out of curiosity, are you using any OCR technology? And do you find it inadequate in handling the documents you've described?


John Halamka said...

We use OCR technologies only to insert the scanned images into the right record (OCR of bar codes). Captiva provides all these solutions

We do not use OCR for medical content, since it is too risky i.e. HIV+ might be OCR'd as HIV-, creating medical error.

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Anonymous said...

ForImage scanning some matlab or c code that obtaines the I,P,B frames from an mpeg movie.