Health Information Technologies & Processes

Point of Care Scanning

  • 1.  Point of Care Scanning

    Posted 6 days ago
    ​Hi All,

    Hoping for some feedback and best practices from hospital systems that have successfully implemented point of care scanning on their inpatient units. Last May our organization pushed hard and fast to achieve HIMSS7. POC scanning was one of the large components of achieving HIMMS7 as we had always scanned/indexed post-discharge. Nursing Informatics delegated the task of scanning to unit clerks across 5 acute care hospitals. Documents would be indexed by HIM at an off-site central location.

    Fast forward to today and we have major quality issues. Relying on unit clerks to scan and own this process has not been effective. We are performing QA on 100% of the documents that come back to us via courier post discharge. This is necessary because so many documents aren't being scanned at the POC. We have let Senior Management know our intention of having HIM assume the responsibility of scanning on the units. We've piloted a few units and things go well when HIM scans documents left in a designated bin on each unit. However, we always hit one roadblock preventing us from moving forward which is the hard copy patient binders still being used on units that house all already scanned documents for admitted patients.

    Providers, Residents, Nurses and others are placing un-scanned documents into these binders before HIM can scan them.  Despite multiple re-education attempts we still can't seem to break through. We're spinning our wheels on where to go next. Do we eliminate the binders (I can't see providers going for that but it's the ultimate goal), do we spend significant time checking through all binders while scanning, or go another route? Any insight at all would be much appreciated.

    Feel free to reach me by email as well at Kenneth.starkey1@umassmemorial.org

    Thanks!

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    Kenneth Starkey
    Supervisor, Document Management
    UMass Memorial Healthcare
    Kenneth.Starkey1@umassmemorial.org
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  • 2.  RE: Point of Care Scanning

    Posted 5 days ago

    Is it an option to remove the hard copies from the unit after scanning or is there too much of a delay before indexing occurs that staff may need the papers?  For HIMSS Stage 7, it requires "clinically relevant" documents be in the electronic record within 24 hours – what "clinically relevant" documents are you having to scan?  Any chance of eliminating some of those?

     

    Wendy Mangin, MS, RHIA

    Executive Project Director – Regulatory Compliance/Privacy Officer

     

    Good Samaritan 

    520 S. Seventh St. | Vincennes, Indiana | 47591

    Hospital: 812.882.5220 | Direct: 812.885.3487 

    Fax: 812.885.3912 | wmangin@gshvin.org 

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  • 3.  RE: Point of Care Scanning

    Posted 5 days ago

    Hi, I believe you can determine what "clinically relevant" is for your organization. When we plan on doing it, HIM will be taking the hard copies from the units as we will scan them and bring them back to HIM.


    Thanks,

    Karla

     






  • 4.  RE: Point of Care Scanning

    Posted 5 days ago
    Our TAT is in good shape where we are having all records scanned at the POC for inpatient documentation in the EMR in under an hours time. In terms of clinically relevant documentation it isn't an expansive document set. It's outside records from other entities, EKGs (Our EKGs don't interface until about 24 hours until after they're performed), and certain downtime forms. To me our lag time between scanning and having the doc accessible within the EMR isn't an issue. We've even offered to have a single binder on the units with all EKGs for admitted patients in case of an emergency where a provider needs it for reference.

    To me our issue is communication and education. We need the backing from senior leadership and a physician champion to make this work. That and the fact clinical staff need to be willing to transition away from having that hard copy document in front of them, and access the EMR (where they already do all their documenting) to view scans.

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    Kenneth Starkey
    Supervisor, Document Management
    UMass Memorial Healthcare
    Kenneth.Starkey1@umassmemorial.org
    ------------------------------



  • 5.  RE: Point of Care Scanning

    Posted 3 days ago
    Edited by Sarah Keppen 3 days ago
    Unfortunately, I do not have an answer to your original question, but I wanted to make a comment on this discussion thread. It is completely frustrating how clinical staff do not understand their role in ensuring a patient has a complete and accurate legal medical record. This isn't new with EMRs but I feel that it's more pronounced. With front end documentation, quality of provider documentation is going down. There's a reduction of overall documentation, higher percentage of spelling, grammar, and other ​errors. Providers and other clinical staff are inappropriately using the copy/paste feature. The onerous of ensuring a complete and accurate legal medical record too often falls completely on HIM. Working in IT, I often have customers trying to use EMR workflows to drive practice. That never works out as intended. Practice should drive EMRs, not the other way around.

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    Sarah R. Keppen RHIA
    Applications Analyst
    Facilitator Certification Exam Prep Community
    2016 Chair Engage Advisory Committee
    skeppen@regionalhealth.com
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  • 6.  RE: Point of Care Scanning

    Posted 2 days ago
    We no longer have binders on the nursing units. When we migrated from Meditech Magic to 6.15 in 2018, the binders were removed from the floors. It was tough but our leadership stood firm and now they are used to accessing records completely via the EMR. All records are scanned by HIM within 24 hours, most sooner than that. HIM has a pick up schedule throughout the day and anything picked up is scanned and indexed within 1 hour of pickup. (We are a smaller facility, 49 acute beds, 51 long term care and 20 psych.)

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    Kathryn Wood, RHIA
    Assistant Director of Information Systems/Privacy
    War Memorial Hospital
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