Section 6.

9 Optimize

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 Optimization Strategies for
Electronic Document Management
Systems
Many health care facilities preparing to adopt an electronic health record (EHR)
have paper-based records for those they have treated. As part of your chart
conversion and pre-load planning, you will need to determine whether to keep the
paper records, scan all of these records, scan only records for active clients, or scan
only parts of active clients’ records. Understanding the options for scanning and
other forms of document management—and preparing to use such systems—helps
manage the scanning process and supports use of the scanned record content.

Time needed: 4 – 6 hours

Suggested other tools: Section 2.4 Visioning, Goal Setting, and Strategic Planning for EHR and
HIE, Section 2.6 Workflow and Process Redesign for EHR and HIE, Section 2.13 Chart Conversion
and Pre-Load Planning

How to Use
1. Review your chart conversion and pre-load planning to determine the
potential size and nature of your scanning project.
2. Review the types of electronic document management systems (EDMS) to
determine which type is most suitable for your facility.
3. Develop a plan for implementing EDMS.

Types of EDMS
Different types of EDMS provide a continuum of features and functions, from
simple to sophisticated. The following are the types of EDMS used most
frequently in health care:
 Document scanning is performed using a scanner with scanning software
that scans the document and enables it to be moved into a folder on a
computer. The individual performing the scanning saves the scanned image
of the document as a file and then saves it to an appropriate folder. This
approach is satisfactory for occasional scanning, but is too time consuming
for scanning health records in bulk (such as for scanning all archived
records). Each document in a record could take 15 to 30 seconds to
prepare, 15 to 30 seconds to scan, and 30 seconds to a minute or more to
index (for a total of one to three minutes per page).
 Electronic document management systems (EDMS) help manage the
indexing and filing of documents. This type of system is used for bulk
scanning to archive and occasionally to retrieve scanned records. It is the
most common form of scanning in health care. Within EDMS there are
various levels of functionality:
o Basic indexing support is achievable using more sophisticated
software that supports reading a leading separator sheet and sub-

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 header separator sheets for each type of document (e.g., notes and
orders) placed throughout the set of documents or record.
o Automated indexing support use barcodes placed on each
document that designates who the record belongs to and the type of
document. Barcoded labels can be run for each record to be placed
on a document. Labels can also be acquired to designate type of
document or forms can be printed with the barcode designating the
type of document so only names needs to be added. Software
places each of the documents that are scanned into the appropriate
folder and arranges the documents according to type. If the date
each document was created is on the barcode label, the documents
can be filed in date order within their type. Optical character
recognition can also be used for indexing. The more indexing
incorporated, the more time it takes to prepare the documents for
scanning, but the easier they are to retrieve later.
o Electronic feed of documents is a feature of EDMS that is
important if your health professionals use dictation, receive
electronic faxes (e-faxes), and/or receive email that need to be
incorporated into your EHR. The ability to transmit the voice file,
transcribed document, e-fax, or email directly to the EHR is a
significant time saver rather. Alternatively, you have to print these
out and scan them back into your system. In the past this
functionality was referred to as computer-output to laser disk feed
(COLD-feed). Today most of the electronic feeding of documents
is performed on magnetic disks, but you may continue to hear
references to COLD-feeding.
o Workflow support is another feature of document management
software. This enables the facility to set up rules for processing
various documents. The software alerts a staff member to retrieve
documents designated for a specific type of processing. For
example, if certain documents should be directed to a person who
assigns diagnosis and procedure codes for billing purposes, the
workflow software directs that person to the applicable records.
Workflow support is very useful if document scanning is the
primary means of storing active records. More commonly, the EHR
itself provides workflow support.
 Electronic content management system (ECMS) incorporates the above-
described functionality and also is able to designate content to be “read”
and processed by the computer. There are two ways to achieve this. On a
text document that will be scanned, a few items of content may be
designated with a barcode or optical character recognition to be extracted
by the computer for subsequent processing. For example, if you wish to
run a report on most frequent condition treated, the most frequent
condition (or diagnosis code) would be extracted by the computer. More
often, an e-form is used in ECMS. This allows extraction of data from the
entire form for collection and processing by the computer. The e-form may
include a mix of barcodes, optical character recognition, object mark

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 recognition (“bubble” forms), and intelligent character
recognition/handwriting recognition and/or speech recognition.
ECMS can be very useful when coupled with an EHR. For example, you
could ask an individual to complete an e-form questionnaire in the waiting
room. The questionnaire is then scanned, making the data readily
accessible in the EHR. For this to be achieved, the ECMS software must
be compatible with EHR interoperability standards, especially Health
Level Seven (HL7). (See Section 1.3 Interoperability for EHR and HIE).
Increasingly, tablets are replacing e-forms; the individual in the waiting
room would be handed a tablet on which to complete the questionnaire,
which would be designed as a special template within the EHR. Access to
other parts of the EHR would be restricted through security controls.
 Enterprise content, collaboration, and communications management
systems are not commonly used to support health care services, but can be
helpful for business purposes. For example, when several individuals are
contributing to the development of a document, enterprise content,
collaboration, and communications management aids in version control
and enables all parties to interact simultaneously as the document is being
created.

In addition to different types of scanning software systems, there are image

formats that result from the scanning process. The four most common are:
 .PNG is suitable for text images or detailed drawings. There is no loss of
image data when the image is scanned. PNG files can be very large,
reducing the time it takes to retrieve them.
 .JPG is a good choice for digital photos and other colorful images. This
format compresses the size of these files, making them smaller and faster
to access than PNG images, although there is a slight loss of image quality.
 .TIF overcomes the loss of quality in the JPG file format while still
compressing the size of the file. These images are also versatile because
you are able to apply data tags, resulting in ECMS capability. However,
these tags are not standardized so they are compatible only with the
software that created the image—and not compatible with EHRs.
 .PDF is probably the best choice for text documents. Some programs, such
as Adobe Acrobat, use optical character recognition technology to scan text
characters of the text. You can edit the text later and search for words or
phrases in the document. Adobe Acrobat can also be used to create
templates that can be filled in or to affix an electronic signature to the
document. Since the PDF format includes automatic image compression, it
is a satisfactory choice for scanning images.
 The PDF file format is the most “standardized,” in that anyone with any
computer can retrieve and use a PDF file with a (freely available) reader.
However, this process does not incorporate the content of the PDF file into
an EHR. To do so, the PDF file must be transported to the EHR (from the
scanning software or other source of the PDF) as an attachment to an HL7
message. The transporting mechanism would provide information on how

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 the PDF file should be indexed and where it should be filed, as well as how
the PDF document is made known to the user.
Finally, there are different types of scanners and other associated equipment:
 Flat-bed scanners scan one sheet of paper one at a time. They are not
satisfactory for bulk scanning, but are useful for scanning objects such as
insurance cards, driver’s licenses, pages from a book, etc. Different sizes
are available. If only small items are to be scanned, a small scanner can
easily fit on a desk.
 Sheet-feed scanners automatically scan multiple pages, one after the other.
They are most suitable for bulk scanning—although staples, sticky labels,
and odd-size forms will not go through these scanners.). Different sizes are
available. If you plan to scan records routinely, it would be appropriate to
acquire a sheet-feed scanner that is heavy-duty enough to withstand a lot of
scanning. However, if you plan to scan all archived records and then only
scan occasional documents, it may be suitable to lease a large-scale sheet-
feed scanner for the archived record scanning project and then buy a flat-
bed scanner for occasional use.
 Dual-monitor workstations often are used in large-scale scanning
operations. The scanning equipment operator can view two scanned pages
simultaneously, or view the indexing structure and a scanned image
simultaneously.

Selecting and Implementing EDMS

Selection
o Although some EHR systems incorporate EDMS functionality, many EHR
vendors are moving away from proprietary EDMS offerings. Instead, they
are recommending EDMS vendors with whom they have worked, to
ensure compatibility. Even if your EHR vendor offers EDMS functionality,
it is advisable to consider other options. If you will primarily be archiving
records for occasional retrieval, you might consider using an EDMS
contractor who can do the job faster and often for less cost than hiring and
training your own staff and buying or even leasing your own equipment.
However, if you anticipate scanning a fairly large amount of documents on
a routine basis, you will probably need to acquire the necessary equipment
and software, and determine whether existing staff, additional staff, or
part-time staff can perform the scanning.
o When searching for EDMS vendors online, be sure to set your browser to
electronic document management systems in health care. Several other
industries, such as education, are heavy users of EDMS. Vendors for these
industries will not necessarily provide the same functionality you need.
o Approach the selection of EDMS as you would section of your EHR. Issue
a solicitation for a bid or proposal that describes your needs in detail (see
Section 3.4 Soliciting Bids for EHR and HIE: RFI, RFB, RFP). If you
already have an EHR, identify it so that vendors can determine
compatibility. Describe the volume of documents you have to scan and
their age. This is important for determining the nature of scanning

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 technology, the amount of storage, and the level of indexing needed (older
records will be less likely to be retrieved, so do not need as much
indexing).
o Make sure you are addressing backup storage. You may use a server to
store all of the scanned images, but you should also have either another
server at a remote location or, at minimum, backup CDs stored at a remote
location. Rule of thumb: The contents of one four-drawer file cabinet will
convert to one CD.
o If you are soliciting bids from a contractor to perform the scanning for you,
determine if scanning will occur onsite or offsite. If only offsite is offered,
you will want to ensure that the company is fully bonded, and may even
want to inspect or require that an inspection of the facilities to ensure
security. You should specify whether you want the paper warehoused for
an extended period of time, warehoused temporarily, or destroyed
immediately. Because your scanned images are accepted in a court of law
under the best evidence rule, you will most likely want to destroy them.
However, you may prefer—or the state in which you operate may require
—that paper documents be warehoused for a few months, allowing you
can identify any issues with documents that are missing or were not
scanned properly. It is advisable to check with your attorney before you
decide when to destroy the original paper records.
o If you will be doing your own bulk scanning for archival records, two
other considerations are important:
 Space to stage document preparation, scanning, and temporary
storage of records scanned. Some organizations find they do not
have adequate space to perform these functions and need to rent
temporary space.
 Paper destruction services. You may already use a shredding
company to shred confidential documents. These companies
typically supply locked bins in documents are temporarily held
until the bins are full. Then the service comes and puts the bins into
a truck outfitted with a shredder to conduct the shredding at your
site. For a large-scale scanning operation, you may need a locked
storage area, rather than simply bins, to hold the records to be
shredded. You should also obtain a manifest of destruction each
time a batch of records is shredded.

Implementation
It is of utmost importance to ensure that each document has been scanned and
indexed properly. Not only is this necessary because you will be destroying the
paper documents, but your users will not tolerate poorly scanned documents, may
have difficulty finding documents. Many users stop referring to scanned
documents entirely if the process is too time-consuming. Unless you use ECMS,
which recognizes the name and/or identification number of a person’s documents,
there will be no way to find a misfiled document except to open and review every
document that has been scanned—a virtually impossible task.
The following are steps to be taken to implement EDMS:

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 1. If bulk scanning will be performed, ensure space is acquired for staging
and temporary storage. To determine the duration of your space needs,
estimate the volume of documents to be scanned and the time it will take to
prepare, scan, and index them
2. Install and test hardware and software. Ideally, find some “typical”
documents to scan in order to test whether each type of potential issue can
be addressed by the equipment, following your policies and procedures.
3. Develop policies and procedures for initial scanning:
a. Document preparation. In this step each document is examined to
determine that the individual’s name is on the front and back (if the back is
written on), that identification information is correct. Remove staples, repair
torn or dog-eared pages, photocopy any documents on card stock that will not
go through a sheet-feed scanner, arrange documents in date order by type of
document, and ensure all pages are in the proper orientation. If any documents
are of poor quality, photocopying them while adjusting the copy contrast (light
and dark) may improve legibility. If not, write or stamp on the document “Poor
Quality Original” (PQO) and place it in its proper location for scanning.
b. Document scanning. This step requires daily review of the scanner
itself to make sure it is calibrated for proper image quality. Once ready, a stack
of approximately the appropriate number of documents should be fanned and
inserted into the scanner. Once each batch is scanned, the documents should be
compared with the scanned images to make all are included. Check to make
sure that both sides of two-sided documents are included and that the sides are
in the proper order. Make sure all documents are properly oriented. If a
document is PQO, attempt to improve the readability by rescanning with
different sensitivity settings.
c. Second quality control. Ideally, a different person should perform
the same quality control steps as described above a second time.
d. Indexing. If indexing is a manual process, each document image
must be reviewed to determine if all the information is correct and that the
documents belong together. The documents are then moved to their appropriate
folder or a new folder is created. If the indexing process is automated via
barcodes or optical character recognition, verify that each document is placed
in the correct folder. It is helpful to compare the scanner count with the
indexing count and reconcile each batch before moving on to another batch.
e. Third review and quality control. It strongly recommended that a
third quality control step be performed to ensure that the records in each batch
have been scanned and indexed correctly. Some facilities establish a
randomization process to sample records for this final review. If more than the
specified threshold of errors exists, another sample is taken. This moves to
review of the entire batch if necessary.
4. Develop policies and procedures for ongoing management of scanned
documents:
a. If a document is found that needs to be inserted into an already
scanned set of documents or record, this may be done by scanning
the document and manually indexing.

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 b. If there is a problem with an image and the document can be
rescanned from temporary storage, do so and replace the defective
document with the new document.
c. If there is an addendum, correction, or signature that needs to be
added to an existing document that has been scanned and the
original is no longer available, establish policy that reflects how
this is handled in the paper record.
i. For an addendum to be referenced from an existing
document to a new document, the procedure in a. above is followed for the
new document and the procedure in c. ii below is followed for the markup of
the existing document.
ii. To make a correction, print out a copy of the scanned
image and line out the error with a single thin line, indicating “error.” Date and
sign the correction, then rescan as above in step a. Delete the original scanned
image. If there is an annotation to be added to a document (such as additional
information or reference to an addendum), print out a copy of the scanned
image and add the annotation on a separate image to follow, dating and signing
it with the current date and the person making the annotation.
iii. Signatures may be added in one of two ways. A signature
can be added as described in c. ii above. Or, it can be added within software
that follows an electronic signature process. This process designates that a
review of a document and intent to sign the document have been performed by
an individual authorized to do so (having applied unique user identification
and password, or other form of secure authentication process, in order to
retrieve and review the document).
5. Develop policies and procedures associated with productivity standards if
performing bulk scanning operations or large-scale scanning on an ongoing
basis.
6. Train staff members on the policies and procedures you have created.
Training should include actual scanning under supervision until the person
is confident and the supervisor has observed that all appropriate steps are
followed. Monitoring of productivity and quality control should be stepped
up during the training phase.
7. Bulk scanning is a very tedious process. Breaks are needed to avoid
repetitive motion issues and to refresh. It is recommended that not more
than 50 minutes of every hour be spent scanning, with 10 minutes of break
time for the person to exercise, use distance vision, or simply relax.
8. Post-implementation steps should include conducting quality control and
encouraging everyone who retrieves scanned documents to report any
issues in image quality or indexing. Address these by correcting the
specific problem, looking for root cause, and taking broader corrective
action if necessary.

For additional information, see:

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 Document Management and Imaging Toolkit, American Health Information
Management Association, 2012, available at:
http://journal.ahima.org/2012/12/07/document-management-imaging-processes-
toolkit-supports-ehr-implementation/
Automated Systems for Child Support Enforcement: A Guide for Electronic
Document Management, 2007. (Although geared toward social services, this is an
excellent resource for all type of health care providers.) Available at:
http://www.acf.hhs.gov/sites/default/files/ocse/dcl_07_36a.pdf
Fundamentals of the Legal Health Record and Designated Record Set, American
Health Information Management Association, 2011, available at:
http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_048604.hcsp
?dDocName=bok1_048604

Copyright © 2013 Updated 11-20-13

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