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Readers Write 9/15/10

September 15, 2010 Readers Write 6 Comments

Submit your article of up to 500 words in length, subject to editing for clarity and brevity (please note: I run only original articles that have not appeared on any Web site or in any publication and I can’t use anything that looks like a commercial pitch). I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!

Document Management is Good for Business
By Shubho Chatterjee, PhD, PE

Enterprise content management (ECM), also referred to as document management, is a capability with significant potential to centralize content and document storage, streamline and automate processes, and integrate smoothly with other enterprise systems. The business benefits are improved operational efficiency, reduced manual labor, reduced paper consumption, and improved process quality.

ECM consists of a central content or document repository, with indexing and searching capabilities, integrated with automated workflow allowing documents to be routed to appropriate processes and processors. The usage of the system is controlled by access policies at individual and group levels. Examples of use of this system include, but are not limited to, patient admissions, medical records management, invoice and payment processing, finance and accounts management, contract management.

A rigorous vendor selection process is critical to selecting the appropriate vendor. This should include an initial evaluation of functions and workflows where ECM is deemed to impact the most. Additional selection parameters include, but are not limited to, the total future cost of ownership for the proposed system, the projected process improvements and labor reductions, current material consumption, and current storage costs, product functionality, deployment options, and scalability. These parameters should be used to construct ROI scenarios for different options. Both objective and subjective factors should be integrated into the decision making.

Deployment options can be in-house (client server) or SaaS. While the in-house option provides for greater control, it also requires dedicated resources to manage, maintain, and upgrade the environment. SaaS deployment enables access to the system on a subscription basis with the vendor managing and operating the system and associated infrastructure in its data center.

The SaaS option frees IT staff to focus on more strategic tasks that add value to the organization while avoiding the expense of adding more IT infrastructure and resources to manage the system. Key factors to consider here are Internet connectivity and bandwidth and information security. Implementation is also quicker as the vendor completes the system build, configuration, and installation at their data center.

Collaborating to build a solution requires a thorough examination of the current processes across the organization with supporting process turnaround time data collection. This forms a baseline from which process improvements can be tracked in the future. To maximize the impact of the solution, this in-depth, step-by-step process analysis should be used to re-engineer and automate processes using ECM.

Creating efficiencies with this solution is feasible in many areas. After implementing ECM in the admissions department, Miami Jewish Health Systems has a central repository for patient documents. Seamless integration with the EMR application allows authorized users from any location to instantly access the associated patient’s documents from their workstation, eliminating time-consuming manual searches.

Routing documents electronically to employee’s workflow queues allows for faster processing and greater security. Eliminating the need to search for documents or make paper copies frees the admissions staff from tedious tasks and focus on patient care. Medical Records Management workflow has also improved with easy, instant, and effective collaboration across the organization. Medical personnel receive automated alerts for completing charts and associated notes and deficiencies. Previously, this required a visit to the medical records office.

Back-office departments, such as accounting and finance, have a high volume of paper flow and manual process being susceptible to lost invoices, missed bills, overpayment, or underpayment.

ECM deployment at MJHS is automating invoice processing. Invoices are now indexed to payments made and are searchable easily. With this technology, invoice approval is also automated and does not require manual inter-office mailing and completion. Payments are also completed in a timely manner.

As with any technology solution implementation, ECM must be well planned with a cross-functional team. Integration aspects with other enterprise applications must be well thought out. Baseline process documentation and re-engineered processes are also critical for success and before-after comparisons.

Shubho Chatterjee is chief information officer of Miami Jewish Health Systems of Miami, FL.

Regaining Control of Disaster Recovery
By Tony Cotterill

9-15-2010 6-56-26 PM

While working with our clients in hospital IT departments, we come across a variety of data backup scenarios. Some hospitals do full backups nightly, while others rely on an incremental/full backup strategy. Some sites exclude specific applications from their nightly backup simply because the volume is too great to complete in a 24-hour period.

Although there’s no ‘typical’ approach to backup and disaster recovery, a hospital’s data is a vital asset that must be protected. Before deciding how to protect it, however, first you must understand it.

The data landscape in the healthcare industry is more complex than in many other sectors, primarily because of the varied data types – namely, structured, unstructured and semi-structured — that are generated by both clinical and administrative systems. The type of data being secured and protected is inextricably linked to how that data needs to be recovered.

Structured data comes from database-driven applications, such as the hospital information system, radiology information system, electronic health record, and accounting systems. These applications typically generate hundreds of GBs, possibly a few TBs in larger facilities.

Unstructured data comes from applications that produce discrete files that are not associated with a database. Examples include word processing and spreadsheet files, which are routinely created by administrative staff and then stored on file servers. Many TBs of unstructured file data can be a challenge to backup and recovery.

Semi-structured data is produced most commonly by picture archiving and communication systems and document management and imaging systems. Both maintain a database of information (structured data) that references large quantities of discrete files (unstructured data). A PACS database may run on Oracle or SQL, and its size may be relatively small in relation to the many TB of DICOM images that database references.

Once you understand the three categories of hospital data, you can determine how much is dynamic vs. static. The dynamic data, which typically comprises 20-30 percent of overall healthcare information, is accessed regularly, and therefore changes constantly. This is the data you should be replicating every day.

Static data, which probably makes up the other 70-80 percent of your storage, should be treated differently. This unstructured and semi-structured data never changes and much of it will never be recalled again. Nevertheless, regulations and/or institutional policies compel hospitals to store it for five years, ten years, perhaps even the life of the patient.

So here’s the good news: once you’ve identified your static data, you can replicate it and move it to a self-protecting archive. Then there’s no need to include it in your backups.

This combination of backup and archiving provides an optimal strategy for treating each data type with the right method. By understanding the nature of the data in the critical clinical systems, the IT team can deliver both realistic and acceptable data recovery objectives to the business. In the event of a disaster, the organization can rest assured that the data can be recovered in a reasonable timeframe, minimizing the disruption to patient care.

Tony Cotterill is president and CEO of BridgeHead Software of Ashtead, Surrey, UK.

RTLS and Temperature Monitoring Mania
By Fed Up with the Fever

Would someone please tell me what real-time locating systems in healthcare have to do with environmental monitoring? I keep seeing all these temperature monitoring requirements pop up in RFPs and press releases. It concerns me that the healthcare CIO (or whoever is making these decisions) doesn’t realize that temperature monitoring of refrigerators has nothing to do with real-time locating, and even worse, is willing to saddle their wifi  system with this function risking QOS-sensitive systems such as POE and VoIP.

Sure, real-time alerts of out-of-range or variable temperatures are important, but unless you’re subject to that old Bart Simpson joke where he calls up the bar and says, “Is your refrigerator running?” followed by Moe’s inevitable “Yes” and Bart’s “Well, then you better go catch it!” — well, your refrigerator is not mobile! There’s no need to locate it, and certainly not in real-time.

The real-time alerts and reports that healthcare needs related to temperatures of refrigeration units can be easily achieved with over-the-counter probes. Then, just as it would with any other DCC-based system (i.e., “dry contact closure” such as security cameras, alarms, doors, or nurse call lights), the RTLS would respond to certain pre-established conditions (i.e., temperature out of range). These other systems do not rely on real-time location except to “trigger” an event condition. That is, if you want a security camera to come on if a certain tagged piece of equipment enters the egress zone, you need the RTLS as it relates to the real-time location of the tagged piece of equipment.

Temperature monitoring requires no such “trigger.” It requires only that you “push” an alert to an individual (or group) when a particular event is recognized within the event software. No location changes are recognized or recorded. If healthcare organizations could recognize this, they would save a tremendous amount of money and not be subject to the heartache of a low-grade RTLS that does only one thing (wholly unrelated to real-time locating) well.

So I ask what RTLS has to do with temperature monitoring even as I understand why temperature monitoring is so prominent in the RTLS space. It’s an easy way for vendors to make money. So long as the company can write some basic rules, they can provide an alert when temperatures are out of range. They can also record temperatures at regularly scheduled intervals without staff ever having to physically approach the unit.

There’s no doubt it’s an important time and money saver for the hospital. And it’s a money maker for the RTLS vendor. They get to solve a problem for the customer and appear wholly competent on this level, so that when it comes to delivering their RTLS with any level of accuracy, there will be a certain level of trust pre-instilled.

Unfortunately, too many hospitals fall prey to the belief that environmental monitoring is a function of RTLS, so if the vendor can do that well, surely they can locate assets and automate patient flow, right? Sorry, folks, but it’s just not so.

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Currently there are "6 comments" on this Article:

  1. First off, I want to thank Shubho Chatterjee, PhD, PE for bringing up the topic of document management (DM).

    For many hospitals DM is perceived as archaic technology doomed for obsolescence in an EHR dominated world. Hospitals decision makers who adhere to this misconception are missing out on a time-tested and (mostly) inexpensive technology that fills functional gaps in all areas of the hospital.

    Providers with paper medical records should consider DM as significant in their EHR adoption. Some EHRs vendors provide limited DM functionality, while others bundle DM solutions with varying abilities to manage administrative and financial workflows. This however is not the most critical benefit a DM platform can provide. Considered how clinicians will adopt to an EHR while still reviewing historical charts on paper. Does this sound like a practice that could slow down your EHR adoption?

  2. Re: Greg P_The failure of hospitals to provide readily accessible and user friendly indexed medical records (eg progress notes) is an absolute impediment to good care, and insofar as paper records have much better search functionality, most physicians can find thought processes of a particalar day in the past in the care of a patient better on paaper than in any currently available electronic chart system.

    For Chaterjee, are there search functions for key information on the documents stored, or is scrolling the method of choice?

    For Cotterill, back up systems have been known to fail, more often than the vendors are willing to admit. The problems from failed electronic back ups and inaccessibility of information are pervasive and more dangerous than any problem experienced with paper records. Ask any doctor trying to access unique components prior medical records stored electronically by hospitals whose focus is on billing rather than patient care.

  3. Re: Mary. The failure of digitized charts is rarely that of the technology. DM has been around for a long time, and for the most part has become a commodity. I contend failures are born of improper project management and acceptance of a successful techniques (say six sigma?)

    Good DM shouldn’t store documents as a digital blob. Some outsourced DM solutions combine all chart documents into a digital bucket called “CHART”, but this strategy should be a last resort. Independent vendors like DB Technology, Highland and Bottom Line organize charts with tagged meta-data that allows easy user navigation. Hand-writing recognition of progress notes can’t be relied upon yet, but that is a burden whether we are discussing digital or paper.

    Paper must be physically accessed, meaning someone has to let you into the chart room to access historical progress notes. How frustrating is that over the weekend when access to the chart room is not as easy as when the department is staffed? This happens…often.

    Digital records are always accessible wherever the clinician may be. So a physician wants to see historical notes from home, or in the physician lounge, or wants to share those notes with a physician performing a consult.

    Ever ask the HIM director the frustration they experience retrieving checked-out charts?

    Paper can be replicated without audit trail. Who is to know if I make a copy of all my patients’ charts? No one, until that day when you leave your briefcase in the Starbucks.

    Paper can be easily destroyed. Should I enumerate the stories of hospitals that have lost files in their chart room due to environmental catastrophes? Do you know the cost of freeze drying charts so you can recover after water damage?

    There is another option though. You could abstract your most important historical charts into your EHR. This is a great way of combining the old paper-based chart data with your shiny new EHR data, but you will find the cost of that endeavor to be 4-5 times that of DM (even when abstracting is performed overseas with inexpensive labor), and you will still have to manage a great deal of paper.

  4. insofar as paper records have much better search functionality

    That certainly is an interesting claim. I assume this means that the internet will soon be replaced by massive, but easily searched, warehouses full of paper records?

  5. Response to RTLS and Temperature Monitoring Mania; By Fed Up with the Fever from Valerie @Awarepoint.
    First, you’ll notice I choose not to respond anonymously, as I do want it clear I am representing an RTLS vendor, and don’t want my comments to be viewed as having a hidden agenda or as antagonistic.

    Fed Up with the Fever hit a couple of interesting points here, most relevant, is that the acronym RTLS (Real-time Locating Systems) has become somewhat of a misnomer. These “RTLS” systems have moved well beyond locating to provide both location and condition sensing data for a variety of hospital applications. Our particular solution is described as real-time awareness, others refer to location and condition sensing networks, and still others are starting to use the real-time enterprise to describe this emerging market segment.

    To answer the questions raised succinctly – Fed Up with the Fever is not exactly correct. Although there is no “locating” required for refrigerator monitoring in hospitals, as these assets are stationary, there are applications, in food service, blood and tissue transport, etc., where temperature sensitive assets are in fact mobile. Because locating systems provide an enterprise communication network that can receive data from a variety of inputs (including temperature and other environmental monitoring tags), leveraging the “RTLS” infrastructure for data communication is a cost effective way for hospitals to obtain automated temperature monitoring throughout their enterprise. Either way, for mobile or stationary assets, hospitals are choosing to leverage this communication network by adding temperature monitoring tags and software applications offered by RTLS vendors that include the real-time alerts and reports that healthcare needs related to temperatures.

    To clarify another point made – all RTLS systems are NOT, in fact, Wi-Fi based. There are myriad other options for real-time locating infrastructure. We utilize a ZigBee mesh network, which is completely independent of the Wi-Fi network, yet coexists without interference concerns. There are numerous other non-Wi-Fi technologies as well.

    Fed Up with the Fever further opines that “Unfortunately, too many hospitals fall prey to the belief that environmental monitoring is a function of RTLS, so if the vendor can do that well, surely they can locate assets and automate patient flow, right?” Actually, no, it usually works the other way – hospitals select RTLS to provide asset management and patient flow solutions enterprise wide. Once this infrastructure is in place, asset tag options are easily leveraged to provide location, movement and condition data to a variety of hospital applications, including applications like temperature and other environmental monitoring.

    The last point I would make is that there is even more advanced functionality on the horizon that do incorporate locating as part of temperature monitoring, in the area of auto recording and documenting who and when staff respond to out-of-range situations. In this case, tag-to-tag communication can be used to automate a log entry that an out-of-range situation was corrected, which is a key component to Joint Commission regulatory compliance. Non location-based systems will continue to rely on manual documentation of corrective action response.

    I hope that clears up some of the confusion. Perhaps Fed Up with the Fever should look into opportunities to partner with RTLS vendors as opposed to questioning their existence in the temperature and other environmental-monitoring space.

  6. Mary,
    The DM system can be used to search according to selected criteria ro field types, such as, MRN, names, etc. These criteria are defined by functions and users. While some are common, others are function specific. For example, a clinician may be looking for notes, an HIM may be looking for Release for Information status, and Accounts Payable may be looking for invoice number.

    We have spent significant efforts in ensuring that the entire workflow, including cross-functional impacts, are mapped before the solution is designed. For example, while implementing Accounts Payabel and Patient Finance we have looked into Admissions processes and the interfaces with our EMR. Hope this response helps.







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