1. Introduction
2. Preparation of case notes prior to scanning
3. OCR on image ingestion and automated document classification
4. Scanning in colour
4.1 Ease of visual recognition
4.2 Simplifying the Pre-scan preparation process
4.3 Eliminates clinical risk
5. Record tracking
5.1 Step 1: Create Batch labels
5.2 Step 2: Track patient records to a batch
5.3 Step 3: Create a consignment
5.4 Step 4: Automated batch reconciliation on import
6. Balancing EDMS implementation strategy with scanning capacity
7. BS10008 compliance: destroying scanned originals with confidence
8. Appendix A: Pre-scanning preparation rules for case notes prior to scanning
9. Appendix B: Removed material patch page
1. Introduction
A successful EDMS implementation is dependent upon three organisations working effectively in partnership; the Hospital, EDMS provider and Scanning partner. This document describes how MediViewer functionality combined with IMMJ System’s implementation methodology facilitates close working between the three parties, leading to a positive customer experience and cost-effective outcome.
2. Preparation of case notes prior to scanning
The most time-consuming part of the scanning process is in the preparation of case notes prior to scanning. Typically, bureau staff engaged pre- scanning preparation can outnumber scanning staff fivefold and it is in the hospital’s interests to make this process as efficient as possible to ensure that it does not create a ‘bottleneck’ that slows down the scanning process by introducing too many decision points.
To counterbalance this there must be consideration for how the digitised record is presented to the clinician to enhance accessibility.
Regardless, there are certain basic rules of case note preparation that must be observed to ensure that the scanning process is efficient and meets quality and legal admissibility standards. Suggested basic rules for case note pre-scanning preparation are included in Appendix A.
A key consideration in the preparation process is whether any documentation can be removed from the patient’s record and either treated as a ‘discard’ (removed and securely destroyed) or stored and retained in line with record retention policies. Any such decisions must be taken under clinical leadership with input from a broad range of disciplines as there will be different demands placed upon the records.
For instance, the hospital may require that mounted pathology/radiology results are removed from patient case notes. As historic results are usually accessible on line, the clinicians would be able to enquire upon past results where necessary. These documents are time consuming to scan and require careful separation from the mount sheet as well as removing the gummed portion which would otherwise cause the scanner to jam. As pathology requests are frequently signed as an acknowledgement that the clinician has reviewed the results, there may be a requirement to retain the originals to be requested from the storage facility for clinical audit and legal cases.
There may be documents that are difficult or impractical to scan such as CTG traces and X-rays. In this situation they may be substituted with patch pages during the preparation phase and can be recalled from deep storage as and when required. Please refer to Appendix B for sample patch page for removed material.
It is critical that any preparation process is clearly and unambiguously documented. The ‘rules’ must
be simple enough that they can consistently be followed by suitably supervised clerical staff.
Part of the process for finalising the preparation rules for case notes should involve a trial of the proposed option(s). It is important to demonstrate that the agreed rules and structure meets the expectations and needs of clinicians once the case notes are rendered within MediViewer.
To ensure that this preparation process is cost-efficient and easy to implement, MediViewer requires just two user interventions from the scanning supplier perspective:
- insertion of the bar-coded patient cover sheet (generated by MediViewer Batch Manager) in front of the record;
- optionally append a generic QR bar code label to the original patient record separator tab to improve user experience when viewing the digitised
3. OCR on image ingestion and automated document classification
The SmartIndex™ function in MediViewer runs an automated recognition process in real time over scanned patient records to identify any key documents. MediViewer allows the creation of user configurable rules or expressions to recognise documents based on OCR which is performed on ingestion into MediViewer. For example, a history or continuation sheet could be identified by the words ‘history, examination, treatment’ in that order.
SmartIndex™ removes the need for the scanning bureau to perform the onerous task of manually indexing and barcoding documents during the preparation process – MediViewer’s smart indexing takes care of document classification for ease of retrieval by the clinician.
Each user can create their own set of filters which allows them to quickly access groups of smart indexed documents e.g. correspondence or investigations. Smart indexing allows documents to be identified and retrieved regardless of the way they have been filed in the original notes. Since every page in a patient’s record is OCR’d, MediViewer also enables wild card searches. For instance, the user can select all correspondence in the patient’s record and use the wild card search to further refine the letters displayed by entering a specific word such as ‘orthopaedics’. All letters containing that word will be displayed with the search word highlighted in orange.
4. Scanning in colour
MediViewer performs OCR and BCR on ingested images and will receive full colour 300dpi images from the scanning operation. Images should be supplied as TIFF-wrapped JPEG multipage files, to increase accuracy and improve the end-user experience. Once the colour image has been OCR’d, it is compressed for optimum performance.
Although a colour image will be larger than a bitonal image, MediViewer will still load the image into the viewer with sub-second performance as it is designed as a single-stack solution with no dependency on third party software.
We recommend scanning in 300 DPI colour for the following reasons:
4.1 Ease of visual recognition
The MediViewer thumbnail view allows the user to quickly browse the entire patient record.The user experience and ability to recognise documents is enhanced with colour images.
4.2 Simplifying the Pre-scan preparation process
It should be easier and more cost effective for the scanning provider to scan everything fully in either bitonal or colour to eliminate the need for preparation staff to place patch pages into patient records where colour images need to be detected by the scanner.
4.3 Eliminates clinical risk
Preparation staff employed by the scanning bureau are sometimes given the responsibility for deciding whether a page should be scanned as bitonal or colour. These staff are rarely clinically trained and yet are expected to make decisions on whether it is clinically relevant to scan a document in colour.
5. Record tracking
It is critical for the Hospital to have clear oversight of the chain of custody, tracking exactly where patient records are in the scanning process so that they can be assured they are receiving a faithful reproduction of all documentation despatched and can therefore destroy the scanned originals with confidence. The MediViewer Batch Manager module provides assurance that every patient record is tracked, from ’pulling’ records from the library for despatch to import and QC of the digitised patient record into MediViewer. Batch Manager achieves this in the following way:
- Tracking all despatched patient records to a batch and consignment;
- Transmission of a csv file (or similar format) to load into tracking software to allow for reconciliation on receipt;
- Exception processing to deal with urgent requests or missing records;
- Automated reconciliation checks on import into MediViewer for missing patient records and/or batches;
- Ability to ‘quarantine’ imported batches whilst Hospital staff perform their own QC
5.1 Step 1: Create Batch labels
Archive boxes (batches) are allocated a unique batch number on a bar-coded label, created using MediViewer Batch Manager function.
5.2 Step 2: Track patient records to a batch
A batch number is recorded in MediViewer using a hand held scanner along with each bar code on the patient’s folder cover (denoting hospital number) and patient records are placed in the archive box until filled. The hospital number is validated against the PMI. This means that each patient record is electronically tracked to a batch. When the batch is complete each patient record will have a bar- coded patient cover sheet generated to enable the generation of meta data indicating the patient identifier. A batch manifest will also be created.
5.3 Step 3: Create a consignment
When all batches have been created and the consignment (representing a delivery) is complete, an export file can be generated (e.g. CSV format) for transmission to the supplier (e.g. via SFTP). The supplier can upload this file into their tracking software to allow for batch reconciliation on receipt. Typically, this file will contain the batch numbers and hospital numbers contained within, plus patient name and DOB if required (for visual verification). The consignment number can also be included or incorporated into the naming convention for the file transferred. The format is completely configurable depending on the scanning supplier’s requirements.
5.4 Step 4: Automated batch reconciliation on import
Once the scanned output has been QC’d, the scanning provider typically moves the scanned patient records into a drop folder, continuously monitored by the application and imported into MediViewer. Once the records have been imported, there will be configurable latency before the records are automatically purged from the drop folder to avoid duplicate batches/records being generated. Should a record be accidentally presented twice this will be identified by MediViewer and quarantined for further action by the administrator. As MediViewer tracks all batches/records despatched, on importing the records it will flag any batches that either have additional or missing records.
6. Balancing EDMS implementation strategy with scanning capacity
In our experience the preferred EDMS implementation approach is to adopt a phased deployment i.e. deploying the EDM Solution on a specialty by specialty basis using outpatient clinics as the trigger for scanning. In this scenario the Hospital Medical Records team would run the clinic pulling lists from the EPR, but divert the records pulled for patients attending ‘live’ clinics to the scanning service, where they would be digitised ahead of the outpatient consultation. There are several advantages to this approach over ‘Big Bang’ (i.e. going live hospital-wide from day one):
- A phased deployment allows the organisation to be flexible to ensure the scanning services (both back and day forward scanning) can meet agreed SLAs (i.e. turnaround from receipt of records to digitisation). Specialties can go live one after the other or a few at a time depending on scanning and transformation capacity. In the event of any concerns, pulling for the next set of clinics can be paused;
- Clinical engagement and transformation activities are focussed at specialty level enabling concerns to be identified and addressed;
- Process changes are tested, proven and embedded prior to introducing them in another specialty;
- Less resources are required simultaneously to implement/support a phased
From a scanning perspective this means that there will be a gradual increase in numbers of records to be scanned if a phased implementation is preferred. Therefore, the new scanning processes (back and forward scanning) can be fully tested both for quality and ability to meet service levels before volumes increase. However, the challenge for the scanning provider is to predict throughput levels (i.e. number of sheets to be scanned daily) and resource accordingly.
Given that MediViewer holds continually updated patient attendance history and details of upcoming appointments, using the specialty roll-out profile we can reliably predict the future scanning requirements and peak demand. MediViewer provides reporting functionality that can be used to report on projected scanning volumes, weeks in advance, to assist the scanning supplier with their resource planning.
7. BS10008 compliance: destroying scanned originals with confidence
The Hospital needs to ensure that robust procedures exist and that all operations carried out within the Scanning Bureau and supporting services are carried out in a manner that complies with all relevant Legislation and Standards of Best Practice.
It is of paramount importance to the Hospital that the integrity and availability of the patient Health Record is not compromised in any way through the scanning of paper records. It is also important for the Hospital to be able to destroy such paper records once they have been scanned to enable the release of essential savings relating to the cost of storing scanned patient records. To destroy the originals after scanning represents a clinical and legislative risk. The best way to minimise those risks is to ensure that the Hospital is able to demonstrate compliance to a best practice standard.
IMMJ systems recommend that before the Hospital commences the destruction of the scanned originals from back and forward scanning exercise that an assessment is made of the existing processes and controls in place in order to gain assurances that the Hospital, scanning supplier and forward scanning bureau are operating within rigorous guidelines set out in BS10008, the standard for evidential weight and legal admissibility of electronic records.
MediViewer is BS10008 compliant and ensures the scanned documents cannot be deleted or altered in any way, as well as providing a comprehensive audit trail. The Batch Manager module provides a unique tracking system that provides confidence that each individual record shipped to the supplier are acknowledged on import. IMMJ Systems recommend a two-step process:
The initial stage entails reviewing existing policies and procedures and the proposed processes relating to archive scanning and forward scanning. Conducting the review prior to go-live helps ensure that the Hospital have future proofed their plans and will be following best practice. It includes an overview and opinion on their existing policy framework, project governance and specific requirements relating to the proposed technology relating to the scanning process and MediViewer.
The second phase takes place after go live and includes a comprehensive review of the fully developed procedures, documentation generated and assessing the results of audits undertaken by both scanning provider and the Hospital. The benefits are clear:
- Ability to securely destroy scanned paper-based records without fear of legal challenge;
- Realisation of savings relating to the storage, management and handling of paper
Ultimately, achieving BS10008 compliance is a test of the existence of robust internal processes and underlining technology.
8. Appendix A: Pre-scanning preparation rules for case notes prior to scanning
The following rules can be applied to all patient documentation received in the scanning bureau:
General Rules – remove all paper from the case note retaining the documents in their original order. Remove all metal staples, paper clips, fasteners, elastic bands, bindings, etc. from the documents.
Card Tab Separators – these will ideally be scanned with a generic QR barcode label identifying the section (e.g. correspondence, investigations etc.)
Torn sheets – where paper sheets have been torn these are to be repaired using tape or to cut off and discard the torn part only where the torn section does not hold any information. Alternatively, if damage is severe the document can be placed in a clear plastic wallet for ease of scanning and reused.
Folded or creased paper – These sheets are to be unfolded and the creases smoothed out.
Photographs – Photographs are to be prepared for scanning as per other case note documentation. Small photographs may need to be mounted (using tape) on a blank white sheet.
Booklets – Where documents are bound such as maternity booklets these are to be unbound or the spine removed using appropriate tools and placed in page number order. Under no circumstances should blank or incomplete pages be removed and discarded.
Poor Quality Stamp – to be stamped on all sheets that are of a poor quality or overlapped photocopies, cropped faxes etc. this is to eliminate any unnecessary queries or doubt at QC level. Please note the stamp is to be applied only to an area of the sheet that does not contain information. Under no circumstance should the stamp be applied over any text or drawing. Ideally the stamp will be applied to the top right-hand corner if there is sufficient space.
Discards – No material should be discarded unless otherwise instructed by the Hospital. There may be a Hospital decision for the following items to be removed and securely destroyed:
- Spare patient demographic labels
- Post-It notes
- Blank forms (i.e. forms inserted into the record that have not been completed)
Small documents – Small sized documents i.e. urine sample results, typically ‘till receipt’ size should be removed if within an envelope and taped to a mount sheet in place of the envelope. If attached to an existing document, then it must be viewed to ensure that it does not cover any text or written information. If this is the case then it must be re-sited and the sample taped on to the document on either side where there is a clear space and the sample taped down two sides so that it can be seen that there is no information behind. In the event that there is not a clear space then a plain sheet of A4 paper is to be used as above.
Use of wooden angle block – All preparation stations can have wooden blocks which are erected with right angles to ensure that the documents are stacked with straight and square edges. The documents to be scanned are to be placed in the wooden blocks face down with text orientation in the upright position. The block should be used at all times during this stage of preparation to keep edges tidy and uniform. Small documents (e.g. A5) should be placed in the middle of the angle block to align with the scanners feeder tyres (dependent on scanner model). This is important as this will assist the banding, handling and scanning of the documents.
Banding -The prepared documents are to be banded with batch log sheet and placed in a box or area close to the scanner operator.
Preparation process for oversized documents or non-scannable items:
Material that is too large to be scanned (e.g. ECG, EEG, CTG, CCU/ITU charts) should be replaced with a Patch page, “Removed Miscellaneous Material” (refer to Appendix B) and completed by ticking the appropriate box and completing the information requested. Please note that if the ‘Other’ box is ticked a description of the removed document should be provided.
Non-scannable items –these items typically include X-Rays, CDs etc. They should be removed from the patient record during the preparation stage.
Existing envelopes – Where any removed documents are within an existing envelope they should be kept within their original envelope as this may have important information written on.
Typically, removed material will be tracked to a separate archive box and returned to the Hospital with appropriate tracking information.
9. Appendix B: Removed material patch page
