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Document imaging enables health care organizations to gradually transition to electronic health records (EHR). The process of document imaging is seen by many as a bridge to the EHR, and scanning, or imaging, enables a health care organization to interface multiple yet separate technology systems. While patient records are being scanned, health care organizations have time to locate or create and develop EHR solutions to meet their electronic record-keeping needs. Document imaging, however, is not a real EHR, but is the electronic storage of paper records (“AHIMA Practice Brief: Document Imaging as a Bridge to the EHR,” Harry Rhodes and Michelle Dougherty, Journal of AHIMA, June 2003).

Once a health care organization implements a document imaging process, that does not necessary mean that the documentation process will be re-engineered, or that data will be collected in an organized, standardized manner. Clinical applications for an EHR will be needed to change the way physicians work, and to provide improved medical decision support.

The document imaging system can be implemented to capture clinical information from EHR documentation applications, lab, radiology, transcription, and other departments that a patient encounters during his or her visit to the health care facility. 

Organizations that have executed document imaging have identified the following benefits, according to Rhodes and Dougherty:

• Improved coding/accounts receivable (A/R) processing time – facilities using document imaging programs report quicker coding and chart completion, which leads to more efficient A/R management
• Improved access – document imaging enables greater access to health records for users beyond the HIM department; online records enable multiple users to access records simultaneously and remotely
• HIM work flow – Assembly, filing, and retrieval of records are all eliminated with document imaging technology, allowing increased productivity; computerized records are seldom lost
• Decreased expenses, increased revenue – off-site records storage is eliminated with the reduced burden of papers
• Elimination of retrieval lag time – Time spent retrieving and delivering paper charts is eliminated with online access of medical records
• Cost justification – The expense of document imaging software and hardware is justified through increased revenue, decreased expenses, clerical staff reduction, and improvement in A/R management
• Improved HIM and IS Collaboration – HIM and Information Services (IS) will work together through the management and implementation of a document imaging system

Document Imaging Steps

Once paper records arrive in the HIM department, they are scanned in order to provide electronic access.  The flow and functions of an HIM department do change as these new procedures are executed.

These are the steps involved in document imaging:
1. Scanning
2. Indexing (streamline access and retrieval process by automatically indexing information)
3. Image storage (magnetic or optical storage)
4. Image display and manipulation (size of monitors, features for zooming, reduction, highlighting, electronic signatures, etc.)
5. Printing and faxing decisions (who will be able to print/fax the documents)

The Legality of Scanned Documents

Electronic documents that are not part of an EHR now face the question of legality. Are scanned health records legal? Do they meet the definition of the legal health record? The legal health record is often required for billing, quality assurance, follow-up care, audits, research requests, or legal requests, and the source document (the original document or copies of it) is sometimes required for a specific purpose. So once documents have been scanned and stored electronically, many health care entities destroy the original paper copies and designate the scanned records and the legal records.

If an organization is debating whether or not to use scanned health records as primary legal health records, it needs to review current state laws, particularly those that pertain to maintaining health records in an electronic format for evidence in legal proceedings, facility licensing, and certification. If state laws do not recognize scanned health records as legal, then source documents cannot be destroyed.

Published standards relevant to document imaging and implementation are available through the Association for Information and Image Management (AIIM) and the American National Standards Institute (ANSI).

Document imaging has a positive effect on the revenue cycle. AHIMA reported that facilities acknowledged a significant decrease in the number of A/R and bill hold days during the first six months following document imaging.

Organizations that have implemented document imaging also realized an impact on their coding staff. Document imaging has enabled some coders to work from home, with flexible hours, while some health care organizations choose to outsource the coding work, and also can complete prebilling coding audits.

A document imaging system should enhance a health care organization’s operations, and in order to do so, a clear understanding of the workflow is needed before document imaging is implemented. Analyze workflows for deficiencies and validate protocols to make sure that accounts are moving efficiently.

AHIMA offers five document imaging questions to ask vendors before purchasing/implementing a system (“Using Document Imaging to Strengthen Revenue Cycle,” by Jill Clark, AHIMA, April 2009):
 
1. What type of integration do you provide with the electronic document management system?
2. What type of logging/reporting is provided for department managers to use as tools to manage their processes and review staff productivity?
3. Do you provide proven best practice workflows for revenue cycle areas?
4. Do you have a user forum or user group for customers to learn more, and a place to network and share information?
5. How do you handle HIPAA-related security and reporting requirements?