Developing and Implementing Health Information Management Document Imaging Productivity Standards: A Case Study from an Acute Care Community Hospital

By Valeria Simonetti, MHA, RHIA, and Alice Noblin, PhD, RHIA, CCS, PMP

Abstract

As health information management (HIM) shifts from paper-based medical records to electronic medical documentation, HIM professionals must appropriately manage their resources to produce higher results for their organization’s operational and financial indicators. This case study highlights the experience of the HIM department in a small Florida community hospital in analyzing existing productivity standards and developing new standards with the purpose of improving the document imaging process. The research produced new productivity standards that more accurately represent the time HIM technicians spend performing their everyday tasks. The data collected during this period indicate that the average HIM technician was prepping 844 images an hour, scanning 601 images an hour, and indexing 482 images an hour. While a trend in productivity cannot be identified because different types of data were collected, the department’s standards are now based on more consistently measurable output. The data collected during this study were used to manage the continuously changing workflow processes; improve the staff’s knowledge, skills, and abilities; and identify potential areas of process improvement.

Keywords: productivity; document imaging; process improvement; electronic medical records; calculating benchmarks

Introduction

自制定卫生信息技术nology for Economic and Clinical Health (HITECH) Act on February 17, 2009, the United States has experienced a rapid acceleration in the development and implementation of electronic health records (EHRs).1电子系统的突然增长导致从纸质医疗记录到电子系统的不完整过渡,从而导致由EHR,纸质记录和扫描图像组成的混合记录的增加。混合记录的纸质部分是医疗组织的高成本,每年平均有1,500张病床的医院生产超过9600万张纸张,每年的成本高达380万美元。2These costs can be attributed to the large amounts of paper purchased for the hospital to print paper medical records and to supply fax machines. As maintaining a hybrid environment can be difficult and expensive, HIM professionals are increasingly challenged with heavy workloads, complex workflows, and added documentation requirements. Balancing the complexities and the confusion of health information technology initiatives, especially the EHR, requires HIM managers to be change agents while seeking higher levels of productivity and quality from employees.3Ensuring the efficiency and effectiveness of the document management process provides healthcare organizations with an opportunity to improve on performance measures including continuity of care, length of stay, patient satisfaction, coding quality, and billing denials.

背景

Continuity of patient care following discharge from an inpatient stay relies on the availability of complete medical records, especially for providers not familiar with the patient.4The Joint Commission has provided guidance for the entire healthcare team on successful transitions of care, including the importance of interpersonal communication, EHRs, and paper records.5Timely document management processes are a vital part of continuity of care. The process begins when paper documentation is generated on the nursing units and is completed when the scanned image has been quality checked for accuracy by the HIM department. Defining each step in the document imaging process is crucial to ensuring standardization and clear lines of communication among members of the HIM team.6By studying each step of the process, HIM professionals can better understand the hybrid environment in their organization and work toward implementing process improvements that will provide a smooth transition to a fully electronic record system.

Productivity standards and turnaround times provide needed tools for the healthcare manager.7To ensure completion of post discharge document processing in a timely manner, Bhat and colleagues8applied Lean Six Sigma techniques to turnaround time for discharged-patient records. With new efficiencies introduced and waste eliminated, they were able to decrease paper record processing time from 19 to 8 minutes with assembly, analysis, coding, and filing of the record completed and backlogs eliminated.9While this set of medical record processes is not equivalent to EHR processes in the United States, it does provide some basis for comparison and comment. As in the processes noted by Bhat and colleagues, conducting timed observations to determine exactly how much time is spent on different work types provides a baseline for performance improvements.10

Existing HIM research has focused on transcription and coding productivity or the effects of productivity on quality, leaving a knowledge gap in information on measuring productivity in the document imaging process.11–14When developing productivity standards, management must consider the specialized skill set of HIM technicians and other employees, factoring in learning curves.15Establishing industry benchmarks for HIM document imaging functions has proven difficult because of factors that can affect the process, such as fluctuations in workflow, documentation practices, turnaround time requirements, and equipment.16、17In addition to the core responsibilities of the document imaging process, HIM technicians usually have other responsibilities that vary by facility. Examples of other tasks include answering phone calls and emails and attending to other urgent requests, such as faxing documentation to nursing units and locating documentation for coders. As there is limited published guidance or research on establishing benchmarks, facilities should seek to develop specific productivity measures that have been tailored to account for their organization size, technology, staffing, and designated record set (DRS).

When looking at organizational financial and operational indicators driven by HIM data, such as staffing, reimbursement, length of stay, and compliance, managers need accurate productivity data to make strategic decisions about the future of the organization.18, 19As each phase in the document imaging process is reviewed, management should ask: Why are we performing this task? Is there a more efficient or effective approach to completing this task? What are the consequences of removing this task? How does this task affect the department or organization? Therefore, the purpose of this case study was to revise the existing productivity standards established during the original implementation of the EHR in 2015 so that new productivity benchmarks would reflect the current practices that have evolved as a result of technology and workflow changes occurring in the HIM industry.

Methods

该案例研究着眼于210张床位的公共急诊社区医院。当医院过渡到混合EHR系统时,HIM部门的工作流程发生了很大变化。混合结构要求HIM员工在纸质文档和EHR软件的使用方面都必须熟练,并且必须调整过程以适应两种媒体的健康信息。HIM部门面临的挑战,例如浏览新的EHR,准备和扫描剩余的纸质文档,为未在EHR中捕获的信息创建表格,并添加条形码和患者标签以加快索引过程。此外,该组织还评估了其DRS,以确定DRS和法律健康记录中保留哪些文档,以及应将哪些文档转换为EHR与EHR相对于纸张。

定义过程度量

在这家医院,HIM文档成像团队由三名技术人员组成,这些技术人员在此过程的所有步骤中进行了交叉培训。分解过程中的每个步骤使管理层可以识别可能导致瓶颈的变量。该案例研究中使用的过程定义如下(请参阅图1):

  • Chart retrieval.如果患者在内部,则在患者出院后每天晚上,单位护士秘书每天晚上在患者出院后都会组装图表。第二天早上,他的工作人员从每个护理部门拿起图表。此步骤包括图表检查,以确保在HIM部门收到每个患者的所有文档。图表检查过程是通过将出院的患者清单与从护理地板寄出的图表进行比较来完成的,以确认没有患者图表被放错了位置。
  • Chart preparation.Disassembling the chart involves preparing the chart to be scanned. It encompasses removing staples, grouping similar documents together, rearranging documents in chronological order, taping down monitor strips, verifying that all documents belong to the identified patient, adding patient labels, and discarding documentation that is not part of the DRS.
  • Documents are scanned to produce an electronic version of the documentation. Because of the low volume of paper at the hospital, individual desk scanners are used instead of industrial scanners. During this portion of the document imaging process, the HIM technicians will also apply electronic deficiency indicators to documentation needing signatures.
  • 此步骤涉及将正确的文档类型和患者名称分配给每个表格,这将使文档在EHR中可以识别。在图表准备过程中,技术人员确保每张文档都有条形码,以允许EHR自动应用患者名称和文档工作类型。
  • 质量检验。质量检查包括查看扫描文档,并确定图像是否是将其转移到EHR之前的最佳质量。
  • 事件报告。此步骤涉及报告有可能影响患者安全的文档中的错误,并需要对风险管理进行全面调查。示例可能包括丢失的文档或从护理层发送的文档,患者标识符不正确。事件报告可以在文档成像过程中的任何时刻记录。
  • 杂项。This category includes nonproductive time spent working on tasks that are not directly related to the document imaging process, such as attending meetings or answering phone calls from other departments.

确定当前时间生产

Although steps in the process are defined, variables in a work day can determine exactly what which tasks a technician will perform on any given day. For this reason, time studies will never provide an exact measurement of how much time should be spent on each task. Instead, the time study will provide management with estimates and a general understanding of how time is distributed throughout the process.

Units of work measured in the time study include the following:

  • 图表拾取的分钟数
  • Number of inches of documentation prepped
  • 扫描的图像数量
  • Number of images indexed
  • 检查文档质量的英寸数量
  • Number of incident reports entered
  • 几分钟内的杂项(非生产性)时间

Time studies were performed to collect data three times between August 2017 and August 2018. The initial time study was used to calculate benchmarks, and the following two studies tracked trends over time and measured changes in productivity. Over the course of one year, the hospital experienced one upgrade to the EHR and significant workflow changes in the HIM department.

他的技术人员用来输入数据的工作表,显示了最终时间研究结果的一个例子,可以在图2

In addition, current productivity reports for this study were obtained from pre-designed or “canned” productivity reports created by the vendor and generated in the EHR. The EHR utilized used at the hospital included reports that measured productivity for two functions: scanning and indexing. The reports provide productivity data by user, including the number of images scanned or indexed, and the length of time to perform the functions.

Developing Benchmarks (Calculating Productivity Expectations)

After time studies were performed, the process of establishing benchmarks began with calculation of the average amount of time each technician takes to complete tasks. Labor productivity was calculated using the following formula:

Labor productivity = Total work produced/Total time to complete work

在此公式中,劳动生产率表示完成生产的工作所花费的时间。基准是通过将技术人员完成任务完成的部门(即图表检索或扫描)中生产的工作数量(即图表检索或扫描)来建立的。20

The original productivity standards that previously existed in the HIM department were measured by inches, not images, so it is not possible to provide a direct comparison between the two sets of productivity benchmarks.

建立工作时间工作

确定需要员工需要生产的小时数以确保准确性和问责制。每位技术人员每天负责7.5小时的工作或每周37.5小时,以征收有偿和无偿休息。带薪休假需要每周调整小时。还记录了在其他任务上花费的时间。

Creating a Productivity Log

Maintaining a productivity log provides a mechanism for technicians and managers to track efficiency trends over time (see图3). Using spreadsheet or database software such as Microsoft Excel or Access, technicians can enter their work produced daily. This includes the amount of miscellaneous “trash” documents (documents not prepped and scanned) to ensure that the technicians receive proper credit for their time.

实施新的基准

在新的生产力establi基准shed, the process of implementation involved transitioning from the previously established standards to the newly created standards. Because the last set of time studies concluded in August 2018, the implementation date was set for October 2018 to allow time for employee education and to coincide with the start of the new fiscal year. In the time between August and October, management trained the HIM technicians on the new benchmarks, explaining the reasons for the revisions to the existing standards, the methodology used to arrive at the new standards, and expectations for performance according to the new standards. Starting in September 2018, the new standards were implemented on a trial basis to identify any potential variances, and in October 2018, the new productivity standards went live.

Results

Commencing with the EHR implementation in 2015, HIM technicians measured the total inches of chart documentation picked up each morning. Documentation produced over the past four years shifted from 20-inch batches to batches of less than 1 inch, making it difficult to obtain an accurate measurement. Another prevalent method of measuring productivity is by weight; however, the light amount of documentation picked up in each round made it difficult to attain an accurate weight on the scale.21尽管原始和修订的生产力标准的工作单位不同,但原始基准的数据包含在图4to allow for further analysis.

The new benchmarks, based on the results of the productivity studies, are shown in图5。时间研究表明,平均而言,一名技术人员在60分钟内扫描了600张图像,表明扫描的基准应在一小时内为600张图像,或每分钟10张图像。图6与新建立的图像扫描基准相比,一位技术人员的生产力。平均而言,数据表明技术人员能够在大多数日子里超过基准。

Spreadsheets are used to compare technicians’ results to the benchmarks to determine if the technicians are sufficiently productive according to current productivity standards. These spreadsheets also allow for data analysis by specific measures including type of task, individual technicians, or time period.

Discussion

Changes in technology and organizational workflow processes such as electronic forms and order sets, signature pads, and desktop faxing resulted in a gradual reduction in the amount of paper generated and placed into the charts. Smaller paper charts led the HIM department to consider alternate measurement methods. With implementation of a system based on the number of sheets (or images), potential error caused by human measurement is limited, as the EHR measures the number of images scanned and indexed, and the number of images prepped is measured in the quality check process.

Ultimately, because of the various changes mentioned in this article, HIM leadership made an organizational decision in summer 2017 to change the timing of the document imaging process and chart analysis from post discharge to concurrent (while patients are still in house) to improve continuity of care and optimize resources.22HIM technicians now visit the nursing unit multiple times a day instead of doing a single early-morning pickup. This allows the HIM department to begin the document imaging process immediately upon the patient’s admission, resulting in quicker analysis and record completion.

While significant workflow changes occurred within the HIM department and the organization, these changes had a positive effect on productivity. Using technology to reduce the amount of paper and reorganizing the flow of work into the department decreased the volume of work needing to be completed and made the work more manageable for staff, thereby decreasing daily employee burnout.

Using the productivity log to investigate trends in the HIM workflow allowed management to identify potential process improvements that would remove bottlenecks delaying the progression of document imaging in the department. Designing the productivity tracker to identify trends in aggregate data from all the technicians, as well as in data from individual technicians, allowed for comparisons of individual technician performance based on the organization’s needs.23For example, in this hospital, the tracker identified poor productivity in one otherwise high-performing technician, which allowed management to pinpoint certain processes where the employee need retraining. Analysis revealed that the low productivity was not directly connected to performance but to secondary factors including the technician’s scanner and chart pickup route. Additionally, the tracker trended an increasing amount of miscellaneous “trash” documents being picked up from the floors, which directly correlated to increased amounts of time spent on prepping. Identifying this trend presented an opportunity to provide nursing staff with education on documentation.

尽管设计用于衡量生产率的方法是为了说明几个变量,但使用自我报告的数据是一个限制。他团队的不同成员报告的数字可能过分或低调。但是,将基准测试与来自Ahima的信息进行比较表明该部门处于行业标准范围。24为了验证报告数字的准确性和一致性,组织应定期审查和更新其文档成像过程和生产力期望。

The researchers identified two potential areas for future investigation. First, re-creation of this study in a larger hospital or multihospital system would assist in validating the productivity rates. However, as noted, internal processes, equipment, and other factors vary greatly in different facilities, making comparisons difficult.25第二个要考虑的领域是EHR创建的文档成像生产力数据,这可能会为HIM行业提供有关哪些EHR软件具有更有效扫描和索引功能的信息。

Conclusion

Determining standardized industrywide HIM productivity measures for operational tasks is nearly impossible because of the variables that can fluctuate among hospitals. For this reason, it is crucial that HIM departments work toward developing their own organization-specific productivity measures to ensure they are accounting for all variables that could affect the document imaging process. Overall, the process of designing an accurate productivity system at a small community hospital can present unique challenges. Although EHR-generated reports are useful to compare to the time studies for a well-rounded picture, one must also account for potential inaccuracies. The report may not include images that were rescanned for quality, or it may not account for technical issues with the scanners. An accurate and complete medical record includes high-quality images of all scanned documents, and continuity of care relies on availability of the information. In this manner, efficiency in the HIM department translates into efficiency in patient care.

Valeria Simonetti, MHA, RHIA, is a health information management operations manager.

Alice Noblin, PhD, RHIA, CCS, PMP, is health informatics and information management program director and associate professor at the University of Central Florida in Orlando, FL.

Notes

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