Reimagining Document Management and Data Abstraction

The process of document flow in the medical office is not only cumbersome, but can cost staff upward of two hours per day per physician, and may delay critical information from reaching the appropriate destination. Not only does this introduce some level of risk into the organization, but it doesn’t allow a practice to be nimble in responding to emerging dynamics such as population health management and value-based care, which are built on a foundation of accurate and swift data capture.

The Consequences of Inefficiency

The ramifications of reactive document management are far reaching, going beyond inconvenience. For example, when practices have unwieldy processes, those processes hinder their ability to provide proactive and efficient care, which are key elements in population health management and value-based care initiatives. Even if everything runs smoothly, it can take five to seven days for the typical medical office to address documents, which leaves clinicians waiting for critical data or not knowing that such data is available in the first place. This makes it hard to design proactive treatment strategies and streamline care processes, and, if data is lost, delayed, or misplaced, it can lead to risky situations in which decision making is impaired, duplicative care occurs, or treatment is omitted due to lack of information. Patient satisfaction also can suffer, because an individual is waiting for critical test results, and the longer the delay, the greater the frustration.

As paper piles up, staff members can’t help but feel overwhelmed.

In addition to keeping the practice from progressing toward better care quality, the paper problem can lead to staff and physician burnout. As paper piles up, staff members can’t help but feel overwhelmed. They are under pressure to respond to the needs of patients who are coming in for appointments, calling the practice with questions, and trying to check out after seeing their physicians. At the same time, staff members are being tasked with rapidly and accurately sorting through reams of paper and making sure they don’t inadvertently put something in the wrong spot. This crushing feeling can lead to burnout and turnover. Staff dissatisfaction can trickle down to patients as wait times get longer and customer service interactions are short-changed. Physicians also are affected because they worry they will miss critical documents that are not filed in a timely manner or placed in the right spot.

In the end, poor document management can propagate a recurring scenario where staff members are unhappy because they feel overwhelmed, physicians are concerned because they don’t know if they’ve seen all the pertinent documents, and the organization is constantly put at risk for negative events that could have an impact on compliance and reimbursement, and, in the worst case, result in malpractice suits. This constant cycle does not cultivate a breeding ground in which forward-facing clinical and operational initiatives, such as those aimed at improving quality while reducing costs, can succeed.

Strategies for Overcoming the Problem

Organizations have been wrestling with document management for a while, and some tactics are emerging that are starting to address the issue.

Digitization

Ideally, the best way to address the paper problem is to prevent it from occurring in the first place. When practices can digitize test results, images, and referral notes and send them directly into discrete locations in the electronic health record (EHR), the amount of paper drops dramatically, and the organization can access information more readily. Although some progress in this area has been made, the healthcare industry as a whole is far from being able to do this on a consistent basis. Roadblocks such as lack of interoperability between diverse systems are delaying progress.

Centralization

Another approach involves centralizing the document management function. For example, an academic medical center may create a consolidated information management division through which all data that need to be entered into the EHR flow. Dedicated staff review the materials and upload them into previously agreed-upon locations so that providers can easily find them. Although centralizing can address many of the challenges with document management, organizations pursuing this option often find it hard to scale because it requires a degree of resources that most offices simply don’t have.

Pushing the Burden to the Patient

Yet another method involves leveraging patient portals to shift the onus of uploading documents from the healthcare organization to the patient. Using this technology, individuals can scan in their own information, complete necessary documents, enter refill requests, and input additional data directly into the portal. Although this lifts some of the burden from staff, it won’t address all the paper coming into an organization. Plus, since patients are slow to adopt portals and are not using them consistently, this approach may not be ideal. Your sickest and frailest patients are the least likely to comply.

Health Information Exchanges

Health information exchanges (HIEs) serve as a less resource-intensive version of a centralized option. When designed well, these third-party data repositories can aggregate documents following a rule-based filing system. Practices can link their EHRs to the data repository and view patient information in a semi-standard manner because the data are organized by certain identifiers. However, the usefulness of HIEs depends on how many organizations submit data to them. If one organization participates, but surrounding facilities do not, then there is still paper coming into the practice.

Outsourcing

Outsourcing aims to address some of the limitations found in the approaches described in the preceding sections. By working with a third-party document management partner, an organization can ensure better information handling while minimizing the impact on staff. Such a partner will sift through an organization’s documents; determine whether they are clinical or nonclinical in nature; categorize them into which need to be filed, which need to be reviewed by a physician, or which need to be recycled; and then direct the documents where they should go. The outsourcing partner also will abstract any necessary data for quality reporting. A high-performing outsourcing firm will employ physicians to guide the work, ensuring that someone who understands the language of medicine is heading the program. These physicians will be trained on the naming and filing conventions developed by the specific healthcare organization. As a result, every test result, image and report will be filed consistently according to the organization’s specifications. Because the outsourced partner takes responsibility for any changes in information volume or pace, the document management effort is easily scalable.

A Case Example

To get a sense of how one organization tackled document management, consider the case of Privia Medical Group North Texas (Privia)—a high-performing healthcare organization made up of 72 physician offices and more than 300 providers. The organization is focused on improving population health by treating patients when they are sick, as well as partnering with them to be more proactive about their health thus achieving greater wellness.

The group began shifting away from paper medical records and onboarding an EHR in 2009. At this time, each practice was responsible for scanning in documents such as test results and referral reports. “Every practice had a different way of doing this,” says James F. Parker, MD, a physician leader for Privia (personal interview, October 26, 2018). “For example, a colonoscopy could be categorized in any one of four or five locations, including as a hospital procedure, an outpatient procedure, a consultant report, or a GI study. Not only did this lack of standardization make it difficult to generate accurate quality reports, physicians had a hard time finding things when they needed them. Staff were also frustrated by the amount of time they had to spend sorting, scanning, filing, and abstracting information, especially because the work was not generating the results we wanted.”

In 2013, Privia committed to addressing the issue, working to standardize processes. “We created algorithms and naming conventions, as well as data abstraction procedures, but staff were not consistent about following them,” says Parker. “It wasn’t that they didn’t want to, it was more that they simply didn’t have time. Plus, as staff left, new employees weren’t fully trained, and pretty soon we were back to square one.”

Parker and his team reached out to IKS Health (IKS) for assistance in 2015. The company met weekly with medical group leaders to create a rule book by which to organize documents within the EHR. This included naming conventions, locations, and what information would be abstracted into which fields. Once that was determined, the organization began sending batches of documents to IKS’s physician resources, who would review, file, and abstract data overnight.

Privia Medical Group North Texas has seen tremendous benefits as a result of this partnership. “Our relationship with IKS has helped us get a handle on our documents and also improved the efficiency of data management and abstraction,” says Parker. “Each day, when our staff comes into the office, about 99% of the previous day’s information has been sorted and filed. After no more than three days, all the abstraction is done as well. Not only are IKS staff faster than ours because they are completely focused on this work, they are also more accurate. The company conducts periodic audits to make sure things are consistently filed in the right place. They routinely achieve 99.5% accuracy over thousands of documents.”

In addition to enhanced efficiency, the medical group has experienced huge improvement in its quality reporting. “Before we had fully implemented the IKS program, our mammogram rate for our primary care providers was about 16%,” says Parker. “However, we knew our doctors were performing better than that. Since the results weren’t filed consistently or in a timely fashion, we were missing out on reimbursement. After we completed our IKS implementation, our mammogram rate jumped to 59%. So far in 2018, the rate is 72%. Although some of the jump probably relates to our increased focus on making sure women over 45 have mammograms, the initial jump can be tied directly to the work we did with IKS in document management.”

In addition to tighter quality reporting, Privia has found it can provide more responsive clinical care and reduce the risk of error because critical information for decision-making is reliably at physicians’ fingertips. Staff and physician satisfaction also are up, because employees are able to work closer to the top of their licenses as opposed to sorting through paperwork. The practice even leverages its data management and abstraction program as a marketing tool when recruiting new physicians or practices. “So many organizations struggle with this issue, and when we tell them that by joining our group, they can have their documents seamlessly handled, they are very enthusiastic,” says Parker.

Laying the Groundwork for Success

To be effective in using outside document management and data abstraction resources, organizations should first identify internal champions who will guide the effort. These individuals will work with other stakeholders to develop the standardization parameters.

“If an organization is not committed to the idea of standardization, this approach won’t work,” says Parker. “That’s one of the biggest lessons learned we uncovered as we went through the process. Not everyone is going to be happy with uniformity. Many physicians, especially those who have been practicing a long time, have specific ways of doing things, and if standardization changes that, they can get upset. For us, we established upfront how we were going to sort and store these documents and the reasons behind those decisions. We then stood firm on our methods, which is the only way to do it. That said, as the partnership progressed, even our most skeptical physicians saw this method’s value and benefits, and now we receive little, if any, push back.”

By working with an experienced partner, organizations can take some of the sting out of document management.

Getting a handle on the sheer volume of documents entering a healthcare organization can be a tall order. Although the ultimate goal is to realize complete digitization of information, healthcare is a long way off from this point. Consequently, organizations need to look for other means of addressing the problem to support stronger quality reporting, enable more responsive patient care, and mitigate the risks associated with information lapses. By working with an experienced partner, organizations can take some of the sting out of document management while setting the stage for better long-term performance.