Improving Organizational Efficiencies and Meeting EHR Requirements through Development of a Scanning Procedure

State: FL Type: Promising Practice Year: 2015

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The public health issue was that the Florida Department of Health’s Health Management System (HMS) lacked a user friendly option for scanning documents into the system which was essential for full implementation of electronic health records (E.H.R.).  A hybrid system of paper and electronic medical charts was being utilized which was inefficient and led to duplication of documentation.  As a result of the implementation of a documented process for scanning medical documents, redundancies of efforts were greatly reduced and staff had access to complete information when evaluated clients for medical services.

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Broward County Health Department
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Improving Organizational Efficiencies and Meeting EHR Requirements through Development of a Scanning Procedure
Broward County is located in the southeastern portion of the State of Florida with Miami-Dade County to the south and Palm Beach County to the north.  Broward County is accessible by road, rail, air and sea.  There are 3 interstate highways and Florida’s Turnpike.  There are 2 north-south rail corridors that extend into Miami-Dade and Palm Beach Counties:  the Florida East Coast Railroad Company railway and the South Florida Rail Corridor (formerly CSX).  Broward County has an international airport and three smaller, privately owned airports located within its borders.  Port Everglades Seaport located on the southeastern border of the County services more than 4,180 ships annually.  Port Everglades is one of the top three cruise ports in the world, is among the most active containerized cargo ports in the United States and South Florida’s main seaport for petroleum products such as gasoline and jet fuel.  Broward County’s 2013 population estimate of 1,838,844, represents 9% of the state of Florida’s population, and is the second most populous county in the state of Florida and eighteenth most populous county in the United States (2010 US Census).  Its diverse population includes residents representing more than 200 different countries and speaking more than 130 different languages.  31.4% of the residents are foreign-born.   Broward County is a minority/majority county demonstrated by its 2013 population by race (Black 28.5%, Asian 3.6%, Hispanic 26.9%, other races 4.1%, more than one race .2%, for a total of 59.5% and White 40.8%). The Florida Department of Health in Broward County (DOH-Broward) is the official Public Health Agency in Broward County and has been operational since 1936. It is part of the Integrated Florida Department of Health (DOH) and operates in cooperation with the Broward County Commission under Florida Statute 154. DOH-Broward’s mission is “to protect, promote and improve the health of all people in Florida through integrated state, county and community efforts”.  DOH-Broward is the lead agency providing core public health functions and essential services in the county as part of a complex public health system that includes hospitals, clinics, planning agencies, community-based organizations and others.  DOH-Broward provides population/community-based services to the county’s 1.8 million residents and over 10 million annual visitors, and is responsible for assessing, maintaining and improving health and safety within the county. The public health issue was that the Florida Department of Health’s Health Management System (HMS) lacked a user friendly option for scanning documents into the system which was essential for full implementation of electronic health records (E.H.R.).  A hybrid system of paper and electronic medical charts was being utilized which was inefficient and led to duplication of documentation.  The Florida Department of Health in Broward County (DOH-Broward) Scanning Committee was formed to develop a procedure to supplement Florida Administrative Code (FAC)1B-26.003-Electronic Records and Records Management Practices in order to establish a uniform process for scanning original paper medical documents into the HMS including a systematic method for retrieval and quality assurance.  The procedure applies to all Florida Department of Health in Broward staff. As a result of the implementation of a documented process for scanning medical documents, redundancies of efforts were greatly reduced and staff had access to complete information when evaluated clients for medical services.
Addressing the public health issue of the lack of a user friendly option for scanning documents into the system which was essential for full implementation of electronic health records (E.H.R.) in the Department of Health’s Health Management System (HMS).  A hybrid system of paper and electronic medical charts was being utilized which was inefficient and led to duplication of documentation and access to incomplete information during client visits at multiple service sites.  The Florida Department of Health in Broward County (DOH-Broward) Scanning Committee was formed to develop a procedure to supplement Florida Administrative Code (FAC)1B-26.003-Electronic Records and Records Management Practices in order to establish a uniform process for scanning original paper medical documents into the HMS including a systematic method for retrieval and quality assurance.  The procedure applies to all Florida Department of Health in Broward staff. The Health Insurance Portability and Accountability Act (HIPAA), which was passed by Congress in 1996, specifies who can access or retrieve a patient’s medical records, set limits on the use and release of medical records, and established a series of privacy standards for health care providers to follow HIPAA compliance. The HIPAA privacy and security obligations of a healthcare provider are an integral piece in transitioning to an EMR (Electronic Medical Record)/ EHR (Electronic Health Records) system, but may require adjustments in practice to ensure compliance.The target population for the implementation of this scanning process was all clients who received services at DOH-Broward. In 2013, 106,000 unduplicated clients were seen at DOH-Broward. This process applies to all DOH-Broward 660 staff and any client seeking services at DOH-Broward. 100% of the affected population was affected by this change. The innovation was the development of a user friendly and efficient manner of scanning medical records and other related documents into existing EHR system while ensuring quality assurance processes were maintained.  This innovation improved the quality of services offered by DOH-Broward in that a complete electronic file was available and  accessible to staff seeing clients at any DOH-Broward facility and eliminated the duplication of efforts. The practice is evidenced based in that it utilizes the NACCHO’s Toolbox and is in accordance with implementation of HRSA requirements for electronic health records.
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The Florida Department of Health began the conversion to electronic health records July 2013 but the existing software titled Health Management System (HMS) lacked a comprehensive scanning feature for paper versions of client documents.  HMS is in use at 67 Florida county health departments and no standard existed for the proper scanning of medical documentation into HMS so a hybrid system of paper and electronic records was in place which led to redundancies and duplication of efforts. In addition, if a client was seen at multiple service locations, paper charts were created at each location and information would need to be shared amongst the site the client was receiving services at. For staff to have access to complete information, an electronic system of scanning documents into the existing HMS EHR was needed.In order to be fully compliant with the electronic health records and HIPAA requirements, a scanning committee was formed to develop a procedure for the scanning of documents into HMS that included various subject matter experts such as Health Information, Legal, Management Information Systems (MIS), Organizational Development, HMS Research & Statistics, and clinic/programmatic supervisors.  The committee met on a regular basis to collaborate and determine a policy for the proper scanning of medical documentation into HMS that would be compliant with Florida Statute, electronic health record, and HIPPA requirements. 125 desktop scanners were ordered at a cost of $80 per scanner to a total initial startup cost of $10,000. The scanners were installed for all DOH-Broward EHR users. The committee developed staff training was developed that included the proper use/setting of desktop scanners, how to properly scan documents, and the uploading of scanned documents into HMS. Several layers of security were built into the process along with a four step quality assurance procedure. The Management Information Systems (MIS) Team developed a secure drive to externally back up all scanned documents to ensure a secondary layer of security that worked alongside HMS EHR.  A unified naming convention policy was developed for all scanned documents to ensure documents could be retrieved easily at a later date. The naming convention also ensured duplication of documents would be eliminated as all programs within DOH-Broward with HMS access would have access to the complete client file. Ensuring all client documentation was stored in one central repository reduced duplication of files at multiple DOH-Broward clinic sites, moving of files among sites, plus safeguarded client’s health as all medical providers would have access to complete information related to the client’s care. The scanning procedure benefited the clients who needed to complete less paperwork and were required to bring less documentation to their medical appointments. The Quality Assurance procedure included verifying the quality of the scanned document immediately upon scanning by the staff member scanning a document. Any errors in scanning would immediately be corrected by the staff by re-scanning the documents. The Records Custodian would verify all scanned documents against the paper versions with the assistance of an auditing tool the committee developed that would be utilized to develop future trainings or non-compliance issues. Clinic site supervisors would conduct monthly quality assurance reviews and the Health Information Manager will conduct quarterly reviews of the scanning process.
Primary data sources were collected by site supervisors and the Health Information Systems Manager were collected from HMS EHR and the shared drive was documents were uploaded to.  Data was continuously compared between the two systems to evaluate for quality. If issues were identified, a Quality Improvement worksheet was completed so the staff that made the error could be counseled and it was also used as a training tool for other staff. The medical records scanning procedure created greater efficiency for DOH-Broward programs in that the process eliminated a dual hybrid system of a paper medical record and electronic health record.  The process increased sharing of information across programs in that other DOH-Broward programs would be able to access a client’s file electronically from other program areas which aligned with the electronic health record requirements for meaningful use, phase II for the Affordable Care Act (ACA). Staff time was freed up from the manual creation of paper charts to allow for greater efficiencies on the work unit for other projects. Clinic space that was previously utilized to store files could be opened up to offer additional clinical services to better serve the community. An addition to the process was added in September 2014. The MIS Team worked with the Health Information Systems Manager to develop a database to run reports of scanned documents on a weekly basis as an additional measure to assure quality of scanned documents.  Ongoing staff meeting and committee meetings allow for the sharing of information across programs and locations.  The scanning procedure allowed for a unified medical documentation process which benefited the clients and staff of DOH-Broward. The EHR Meaningful Use Metrics Achieving Target was 54% in 2013 at the start of the implementation of the scanning process. It achieved 100% in February 2014 and is still 100% as of September 2014.  
The DOH- Broward scanning procedure is the first comprehensive scanning policy within the 67 county health departments and for the Florida Department of Health. Due to the successes of this practice, the procedure has become a model of best practice for other health department and has been cited as a best practice in 2 recent programmatic audits.Cost/benefit analysis:• $57,600.00/per year in record storage costs• $20,000/per year in medical record chart product costs • $86,000/per year in staff costs• $160,000 total savings annually• Value Explanation: • Current monthly fees to store records averages $4800 per month X 12 months.• Ordering of medical record folders $20,000 in 2012• Average annual salary per clerk $22,000 (without benefits)Due to the ongoing savings, greater efficiencies in organizational practices and meeting EHR requirements, DOH-Broward is fully committed to continuing the scanning and based on the ongoing cost savings, necessary financial resources will continue to be allocated as needed to continue this procedure.
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