Understanding the intersection between Records and Document Management and Electronic HEALTH Records

Here are some of the things that I think I have figured out about document management solutions and electronic health records and the stimulus program. I send them around not so much under the thought that they are 100% correct, but rather to make get some correction and additions from the collected community.

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So here goes…

There is $23 billion in play in two portions.

One portion ($2 billion) goes immediately to HHS and its sub-agency, the Office of the National Coordinator for Health IT (ONC) and directs creation of standards and policy committees. We (AIIM) are actively working to connect our PDF/H work up with the efforts being directed by the ONC.

The second portion sets aside $21 billion (net) to physicians and hospitals to implement electronic health records. There is a program designed for those who see large volumes of Medicaid patients, and another for those that accept Medicare.

In order for physicians and hospitals to qualify for the incentive payments (that will begin in 2011), they must demonstrate 3 things:

1. Use of a certified EHR product with ePrescribing capabilities that meets current HHS standards.
2. Connectivity to other providers to improve access to the full view of a patient’s history.
3. Ability to report on use of the technology to HHS.

So obviously a central question related to number 1 is who is doing this certification and how does it affect the business of our members?

The legislation does not mandate a specific certifier. Most seem to agree that CCHIT (the Certification Commission for Healthcare Information Technology) will wind up being the certifying organization for acceptable EHR solutions relative to the stimulus funding.

CCHIT is a private nonprofit organization with the sole public mission of accelerating the adoption of robust, interoperable health information technology by creating a credible, efficient certification process. The Commission operates with a nine-member volunteer board of Trustees, 21 volunteer Commissioners who represent all sectors of health IT and provide strategic guidance and oversight for the certification process and criteria, and 170 volunteers who serve on 15 workgroups and bring their expertise to the process of creating the certification criteria.

Last week, CCHIT announced that it has approved final 2009-2010 criteria for certification of Ambulatory (office-based), Inpatient (hospital-based), and Emergency Department electronic health records (EHR), and for its newly developed stand-alone Electronic Prescribing certification. The Commission also approved updated criteria for the Ambulatory add-on options in Child Health and Cardiovascular Medicine. Besides the detailed criteria and test scripts, the Commission will publish a companion guide mapping the criteria to the characteristics of a qualified EHR as described in the American Recovery and Reinvestment Act (ARRA). The materials will be published on May 29 at www.cchit.org.

Speculation seems to be that CCHIT will then become the certifying body and the criteria the framework for determining which solutions will be approved and which will not for stimulus funding.

I am guessing that the criteria will be similar to the existing criteria, which can be summarized as follows:

Organizing patient data – demographics, clinical documentation and notes, medical history
Compiling lists – problems, medication, allergies, adverse reactions
Receiving information – test results, consents, authorizations, clinical documents from outside the practice
Creating orders – ordering medication or diagnostic tests; managing order sets, orders, referrals; generating and recording patient-specific instructions
Supporting decisions – presenting alerts and reminders for disease management, preventive services, wellness; checking for drug interactions and guiding appropriate responses; supporting standard care plans, guidelines and protocols; updating decision support guidelines
Authorized sharing – managing practitioner/patient relations, enforcing confidentiality, enabling concurrent use among multiple practitioners and healthcare personnel
Managing workflow – assigning and routing clinical tasks, managing the taking of medication and immunizations, communicating with a pharmacy
Administrative and billing support – using rules to assist with financial and administrative coding; verifying eligibility and determining insurance coverage

So it would seem that the questions before us are something like the following:

How will CCHIT as the certifying body and some version of the above criteria effect business opportunities for our typical document management solution providers?

How will the crowding out impact that $20 billion in funding on “certified” healthcare IT spending have on existing spending?

For example, here are the kinds of health applications in which many of our companies engage. How will the presence of the above effect these applications?

--Conversion of medical records from paper to electronic
--Offsite storage of medical records
--Chart Deficiency Management
--Release of Information
--Linkages between existing document management solutions and certified EHR solutions
--Patient financial services/EOBs
--Common back office administrative functions

So what do people think? What’s right? What’s wrong? What should we be worried about?

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Tags: aiim, document, ecm, ehr, electronic, emr, health, management, obama, records

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Comment by Michael Jahn on July 8, 2009 at 12:41pm: @ Hal Amens,

Funny thing, I too am in a strange city in a coma - but I have one of these in me;

http://www.healthlinkinfo.com/

so, no - this is NOT outside the bounds of the issues. I have given prior permission, and failing that, I have a trust. Perhaps you are unfamiliar, but when you are 'found' in this condition, and you have no wallet on you (like if you were found on the beach with a surf board attached to your ankle) the Police and EMTs do have procedures they follow. If you are found in a car (or near a car) the Police can use the Vin and then verify identity, but they are not authorized to view health records that the EMT would have access to - if you have a trust.

My point is that it is not so much an issue of having PHR data available in a Google Health.

To the question "what should AIIM be doing" - well, it does not seem to be in the domain of AIIM (as far as I can see) to manage 'what' is being exchanged - it is a shame that while ASTM and HL7 can't really seem to 'harmonize' - perhaps the "PDF Healthcare" - or basically a 'best practicied guide' with detailed use cases - is the best we can do.

there are many issues

http://www.openehr.org/wiki/display/stds/openEHR+Archetypes+for+HL7+CDA+Documents

Comment by Sandra Nunn on May 31, 2009 at 11:50pm: I am the content and information manager for a large integrated delivery system (hospitals, clinics and a health plan) that is spread over an entire state. I now work in IS, but served as the Director of Medical Records in three healthcare systems over the last 25 years. I think the idea that two different entities will divide and conquer the content of the EHR between structured (MDM types) and unstructured information (AIIM) leaves out a very important organization that has been working on electronic health records for decades now. AHIMA (the American Health Information Management Assn.) has been working on these domains and the semi-structured information between them (transcribed documents) for some time now. I have just been commissioned by this association to write a book about what role content management will play in healthcare and its particular relationship to the EHR. I manage an ECM team that is at work developing document and records management, archival (e-mail, etc.), search, etc. I also work with the clinical staff on defining exactly what constitutes our legal EHR and how we will manage e-Discovery and the new HIPAA challenges that HITECH brings. Thomas Pole hit on some key areas that content management can serve like management of images, forms, etc., but there are many more opportunities. I am working with AHIMA to develop competencies for their college's curriculums so that students will come out of school with competencies in content management that will allow them to leverage such systems in healthcare. These students already understand clinical decision support systems, medical coding, etc. which is structured information. We are now working on helping them to understand the unstructured information that constitutes 88% of the information in healthcare (Gartner). In healthcare much of the structured information that is in data warehouses comes from claims data and is somewhat limited, i.e. clinicians don't always use it because it tends not to be timely. It is most often used by administrators who have predefined dashboards focusing on census levels, reimbursement, etc. Data from the EHR may add to these systems, but will probably not be part of them. Clinical decision support (gathered from structured data entered by care givers in the EHR) will be derived and used to improve care methodologies, but may not be a critical part of the data warehouse applications dependent on the organization's profile. In the current economic climate, cost control is king. Therefore, anything AIIM can do to demonstrate cost control would be great. One of my strategies here is to demonstrate how good record and retention management can help us de duplicate documents, e-mail, records, etc. and cut our capacity costs. We are also looking at how many document management systems we have in the organization and how we can consolidate and standardize their operation. Thx, Sandra

Comment by Thomas Pole on May 31, 2009 at 10:08am: I'd like to respond to John's call for input, but before addressing that I would first like to raise what I think is a more basic question: What part does the AIIM community play in a discussion of EHR? Obviously, most AIIM members, especially those of us that are technologists are experienced with both structured and unstructured data, but when we gather and converse at AIIM events and read or write articles in AIIM publications we are concentrating on either unstructured data, or the specialized structured data topic of records management. Databases, data warehousing technologies, etc. are related topics which other professional communities have a stronger claim to then AIIM does, and these technologies are more closely related to the operations one might perform on a traditional electronic patient record; remembering that a health record is a more dynamic entity then a traditional records manager’s record; though the medical community needs that archival function as well. However, the traditional data warehousing industry is not as well prepared as the AIIM community for the management of the large number of inter-related images and document in patient records; especially the sometimes enormous individual DICOM images, and composite image studies.

So here’s my question, what part of the full scope of electronic health record management (I’m purposely not constraining myself to just patient records, which is only one view point of the management of information related work products of health care) is that scope in which the AIIM community has the most to offer to the general discussion?

Personally, this scope question is currently pretty easy to address. At Harris I’ve recently served as the chief architect of an artifact and image management solution for a large network of government owned hospitals (dozens) and clinics (hundreds). The electronic patient record (i.e. structured data) is in a parallel system. We are only responsible for the management of the unstructured data (e.g. diagnostic images, referential images and all forms and other documentation), and interoperation with that other parallel structured patient record system. The technologies for the two sister systems are exactly what you would expect: a database based system for the structured patient record, and an ECM based system for the unstructured data.

Here’s the issue, and the reason why I think AIIM needs to determine what positions it can best play in this game.

In some enterprises, both types of data are in the same system with either the structured (e.g. database) technologies doing a less then optimal job of managing unstructured data (e.g. image management), or the content/image management system doing a less then optimal job deriving applicable knowledge from the structured data. In other enterprises, the structured and unstructured data are in two different systems, which is the technologically logical approach; but from the end users point of view is that the structured and unstructured data for each patient are inseparable aspects of the same patient record; and the interoperation/integration aspect is non-trivial.

In my experience, integration teams that are best prepared for the high performance requirements (nothing is a more real time operation then a surgeon or emergency room MD wanting information from the patient record of a patient they have never seen, much less treated before) of an electronic patient records treatment history; are not the teams best prepared team for dealing with the management of enormous images and other content which distributed across many medical geographically and organizationally distributed facilities.

So here is my opinion of where the AIIM community can best serve:
- management of images
- management of forms and documents from which structured data may or may not have been derived and entered into a structured data system
- archiving of the completed, unchanging, “signed” portions of a patient’s record into a records management archive

Leaving for, or cooperating with the data warehousing/database community, and the knowledge management community to support:
- storage of data derived from forms, documents and image metadata in structured applications (Databases and Data Warehouses)
- Development of business intelligence and executive dashboard applications based on those structured data applications

And because we have traditionally been the community that ends up performing much of the integration between ECM and other systems, the AIIM community can also contribute to the :
- Integration and interoperability between structured and unstructured systems
- Application of business process oriented SOA principles to the overall integrated health record system of systems.

Thomas Pole
Harris Corp.

Comment by John Hughes on May 28, 2009 at 8:53pm: We have transitioned about 75% of our business effort from a healthcare focused ECM solutions provider into an EHR/PM (practice management) solution provider. Our target is the 1-3 physician practices; this is where the bulk of the $19Billion reimbursement is headed. I will try and address some of the comments from above from our experience:
--Conversion of medical records from paper to electronic- I would say here the general rule is to convert recent active patients from go live date, not the back file. Most clinical data will be current and created in the new EHR system.
--Chart Deficiency Management - applies primarily to hospital based systems, still an important function and much needed
--Release of Information - again a good example of how ECM and imaging work in conjuction with workflow to provide this service- but primarly hopsital based
--Linkages between existing document management solutions and certified EHR solutions- this is a big one nearly all the current certiifed EHR's have their own form of document management- generally rudimenatry in so mauch as they provide linking between a scanned image an the EHR patient data
--Patient financial services/EOBs - Hopefully this will now be 100% electronic- some newer EHR/PM systems are single database built from the ground up as an integrated solution-they makes a seamless approach from scheduling the patient, charting the encounter, documenting the diagnosis, ordering tests, electronically creating and submitting the prescription via eprescribing,discharging the patient, capturing co-pay, examining and scrubbing the superbill and submitting to clearing house, and managing the payment and EOB when paid.
of other admin front office duties, or get my billing company to reduce fees to 2or 3%.

--Common back office administrative functions - see above
Hope this helps

Comment by Hal Amens on May 27, 2009 at 11:38pm: Authorized sharing has a number of elements. Here's a couple:

I am in a strange city and in a coma? How will a provider even know I have an electronic record, where it is and who has authority to release it. That looks to me like one of the features of PHR like Google Health -- Google me (if you can figure out who I am) and then see whom I have authorized to release my date, e.g., my wife. That could lead to a series of steps for various types of data.

Do we need levels of authorization by type of data? If I get picked up on a street and put in an ambulance is there some basic data that would be useful to the EMTs but would not represent a serious privacy compromise?

Authorize resolution of a conflict in data about me. I find that two doctors have examined me at about the same time and posted conflicting data? Am I authorized to add the the record to at least point out the conflict so that a user is aware that there is more than one opinion? Can I add what I think is correct? Can either or both doctors comment on the issue and what the other has written?

All of this would appear to be outside the bounds of the issues that would be addressed by the standards setting body but could be very real and very frustrating to a patient. If the system [any part of the system to impacts me] doesn't work, I will try to opt out of it which will further reduce its value.