Health Information Management

Manage information beyond the EHR

JustCoding News: Inpatient, January 20, 2010

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HIM professionals should no longer think of a record as just a paper form. Records now include videos, voice mails, voice recordings, films, and scans. And providers must find a way to keep and catalogue all of it.

Most health information other than codes is unstructured, says Sandra L. Nunn, MA RHIA, CHP, enterprise records manager at Presbyterian Health Services in Albuquerque, NM. Unstructured or semistructured information includes transcribed reports, forms, e-mail, presentations, spreadsheets, and images, and it accounts for 80% or more of a healthcare facility’s information.

One way to get a handle on all of that unstructured data is by using an enterprise content management (ECM) system. ECM allows HIM professionals to gather information from different systems within the facility.

Most facilities have a tremendous amount of content with virtually no control over that content, says Nunn. “People are drowning in information,” she says. ECM can help HIM professionals manage all of it.

Hospitals are storing a lot of information electronically, says Michele O’Connor, MPA, RHIA, FAHIMA, senior director of healthcare practice and chief privacy officer at Initiate Systems in Chicago.

Because HIM professionals plan, collect, aggregate, analyze, and disseminate individual patient and aggregate clinical data, ECM “really hits the sweet spot of what HIM professionals do well,” O’Connor says.

Fundamentally, ECM helps organizations differentiate between data and information, and they can use an ECM system to access this information and to mitigate risks associated with compromised electronic records.

Entering existing documents into the ECM
Most facilities do not have a 100% integrated EHR yet, so some records are still on paper. Other information, such as reports, forms, and presentations, may also exist only on paper. So how do you import that information into an ECM system?

Scanning the documents into the ECM is one option, but when you scan documents, they become images. That means you can’t search for the content contained in that record, which is a definite drawback.

Importing a document in its native format into an ECM is a better way to go, says Nunn, because it allows you to make changes to the document in the ECM and search for information within the document. Over time, digitized documents go into the ECM, and you can check them in and out to revise and update them as needed.

Digitized documents can also complement your EHR, Nunn says. Documents you don’t want altered can be presented in .pdf or .tiff formats to prevent readers from changing secured documents.

Electronic information beyond the EHR
ECM allows you to create electronic order sets and incorporate them into your EHR. You can also keep past versions of documents so you can see how they have changed over time.

You can also add metadata to documents in your ECM. The role of metadata—the information around your data—is growing, Nunn says. Metadata allow you to manage unstructured data and create a searchable environment. Metadata will also allow you to create your own internal searchable environment that will allow people to find information without wasting time.

That searchability becomes especially important when you are asked to produce a specific document or find certain information. Many hospitals are faced with the task of trying to match a mix of record types—some electronic and some paper—when responding to a release-of-information request from a patient, physician, or attorney.

ECM allows you to access different systems and retrieve necessary information quickly and easily.

E-mail is the most requested document in litigation, Nunn says. In the future, e-mail will be part of the health record and EHR when the e-mail is between a physician and a patient or between two physicians, Nunn predicts.

“Plan on considering most e-mail as records,” says Nunn.

This is something most people don’t currently do, she says. But when you have an e-mail that will be part of the record, you need to figure out how to move it to the record.

Using ECM will allow you to capture and archive metadata-enhanced e-mail for cost control and retention management and search and retrieve data for e-discovery and legal/regulatory matters.

Enterprise record management
One way to make managing electronic information easier, Nunn says, is by using an enterprise record management (ERM) system that uses the following five steps:

  • Create. Create demographics, documentation, feeds, authentication, and completion.
  • Use. Make information accessible to providers and other users and establish delivery methodologies.
  • Maintain. HIM works with Information Security to ensure systems’ maintenance, management, and upgrades.
  • Preserve. Preserve records in the legal sense (i.e., legal hold), and in the long-term sense (i.e., retention responsibilities).
  • Destroy. Destroy records and non-records at the end of their life cycle.

Develop ERM for all databases and all record types in any media so you can control and manage all of your records over a long period of time, Nunn says. In addition, develop retention policies for various types of information and make the retention policies automatic, Nunn says.

“Automating retention is extremely important because no human being can keep track of all of the information out there,” she says.

Editor’s note: This article was originally published in the January issue of Medical Records Briefing. E-mail your questions to Senior Managing Editor Andrea Kraynak at

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