Section 6.8 Optimize
Optimization Strategies for Electronic
Document Management Systems
Many health care facilities preparing to adopt an electronic health record (EHR) have paper-based
records for those they have treated. As part of your chart conversion and pre-load planning, you will
need to determine whether to keep the paper records, scan all of these records, scan only records for
active clients, or scan only parts of active clients’ records. Understanding the options for scanning
and other forms of document management—and preparing to use such systems—helps manage the
scanning process and supports use of the scanned record content.
Time needed: 4 – 6 hours
Suggested other tools: 2.3 Visioning, Goal Setting, and Strategic Planning for EHR and HIE, 2.7
Workflow and Process Redesign for EHR and HIE, 2.13 Chart Conversion and Pre-load Planning
How to Use
1. Review your chart conversion and pre-load planning to determine the potential size and
nature of your scanning project.
2. Review the types of electronic document management systems (EDMS) to determine which
type is most suitable for your facility.
3. Develop a plan for implementing EDMS.
Types of EDMS
Different types of EDMS provide a continuum of features and functions, from simple to
sophisticated. The following are the types of EDMS used most frequently in health care:

Document scanning is performed using a scanner with scanning software that scans the
document and enables it to be moved into a folder on a computer. The individual performing
the scanning saves the scanned image of the document as a file and then saves it to an
appropriate folder. This approach is satisfactory for occasional scanning, but is too time
consuming for scanning health records in bulk (such as for scanning all archived records).
Each document in a record could take 15 to 30 seconds to prepare, 15 to 30 seconds to scan,
and 30 seconds to a minute or more to index (for a total of one to three minutes per page).

Electronic document management systems (EDMS) help manage the indexing and filing of
documents. This type of system is used for bulk scanning to archive and occasionally to
retrieve scanned records. It is the most common form of scanning in health care. Within
EDMS there are various levels of functionality:
o Basic indexing support is achievable using more sophisticated software that supports
reading a leading separator sheet and sub-header separator sheets for each type of
document (e.g., notes and orders) placed throughout the set of documents or record.
o Automated indexing support use barcodes placed on each document that designates
who the record belongs to and the type of document. Bar-coded labels can be run for
each record to be placed on a document. Labels can also be acquired to designate type
Section 6 Optimize—Optimization Strategies for Electronic Document Management Systems- 1
of document or forms can be printed with the barcode designating the type of
document so only names needs to be added. Software places each of the documents
that are scanned into the appropriate folder and arranges the documents according to
type. If the date each document was created is on the barcode label, the documents
can be filed in date order within their type. Optical character recognition can also be
used for indexing. The more indexing incorporated, the more time it takes to prepare
the documents for scanning, but the easier they are to retrieve later.
o Electronic feed of documents is a feature of EDMS that is important if your health
professionals use dictation, receive electronic faxes (e-faxes), and/or receive email
that need to be incorporated into your EHR. The ability to transmit the voice file,
transcribed document, e-fax, or email directly to the EHR is a significant time saver
rather. Alternatively, you have to print these out and scan them back into your
system. In the past this functionality was referred to as computer-output to laser disk
feed (COLD-feed). Today most of the electronic feeding of documents is performed
on magnetic disks, but you may continue to hear references to COLD-feeding.
o Workflow support is another feature of document management software. This enables
the facility to set up rules for processing various documents. The software alerts a
staff member to retrieve documents designated for a specific type of processing. For
example, if certain documents should be directed to a person who assigns diagnosis
and procedure codes for billing purposes, the workflow software directs that person
to the applicable records. Workflow support is very useful if document scanning is
the primary means of storing active records. More commonly, the EHR itself
provides workflow support.

Electronic content management system (ECMS) incorporates the above-described
functionality and also is able to designate content to be “read” and processed by the
computer. There are two ways to achieve this. On a text document that will be scanned, a few
items of content may be designated with a barcode or optical character recognition to be
extracted by the computer for subsequent processing. For example, if you wish to run a report
on most frequent condition treated, the most frequent condition (or diagnosis code) would be
extracted by the computer. More often, an e-form is used in ECMS. This allows extraction of
data from the entire form for collection and processing by the computer. The e-form may
include a mix of barcodes, optical character recognition, object mark recognition (“bubble”
forms), and intelligent character recognition/handwriting recognition and/or speech
recognition.
ECMS can be very useful when coupled with an EHR. For example, you could ask an
individual to complete an e-form questionnaire in the waiting room. The questionnaire is then
scanned, making the data readily accessible in the EHR. For this to be achieved, the ECMS
software must be compatible with EHR interoperability standards, especially Health Level
Seven (HL7). (See Section 1.3 Interoperability for EHR and HIE). Increasingly, tablets are
replacing e-forms; the individual in the waiting room would be handed a tablet on which to
complete the questionnaire, which would be designed as a special template within the EHR.
Access to other parts of the EHR would be restricted through security controls.

Enterprise content, collaboration, and communications management systems are not
commonly used to support health care services, but can be helpful for business purposes. For
example, when several individuals are contributing to the development of a document,
enterprise content, collaboration, and communications management aids in version control
and enables all parties to interact simultaneously as the document is being created.
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In addition to different types of scanning software systems, there are image formats that result from
the scanning process. The four most common are:
1. .PNG is suitable for text images or detailed drawings. There is no loss of image data when
the image is scanned. PNG files can be very large, reducing the time it takes to retrieve them.
2. .JPG is a good choice for digital photos and other colorful images. This format compresses
the size of these files, making them smaller and faster to access than PNG images, although
there is a slight loss of image quality.
3. .TIF overcomes the loss of quality in the JPG file format while still compressing the size of
the file. These images are also versatile because you are able to apply data tags, resulting in
ECMS capability. However, these tags are not standardized so they are compatible only with
the software that created the image—and not compatible with EHRs.
4. .PDF is probably the best choice for text documents. Some programs, such as Adobe
Acrobat, use optical character recognition technology to scan text characters of the text. You
can edit the text later and search for words or phrases in the document. Adobe Acrobat can
also be used to create templates that can be filled in or to affix an electronic signature to the
document. Since the PDF format includes automatic image compression, it is a satisfactory
choice for scanning images.
The PDF file format is the most “standardized,” in that anyone with any computer can
retrieve and use a PDF file with a (freely available) reader. However, this process does not
incorporate the content of the PDF file into an EHR. To do so, the PDF file must be
transported to the EHR (from the scanning software or other source of the PDF) as an
attachment to an HL7 message. The transporting mechanism would provide information on
how the PDF file should be indexed and where it should be filed, as well as how the PDF
document is made known to the user.
Finally, there are different types of scanners and other associated equipment:

Flat-bed scanners scan one sheet of paper one at a time. They are not satisfactory for bulk
scanning, but are useful for scanning objects such as insurance cards, driver’s licenses, pages
from a book, etc. Different sizes are available. If only small items are to be scanned, a small
scanner can easily fit on a desk.

Sheet-feed scanners automatically scan multiple pages, one after the other. They are most
suitable for bulk scanning—although staples, sticky labels, and odd-size forms will not go
through these scanners.). Different sizes are available. If you plan to scan records routinely, it
would be appropriate to acquire a sheet-feed scanner that is heavy-duty enough to withstand a
lot of scanning. However, if you plan to scan all archived records and then only scan
occasional documents, it may be suitable to lease a large-scale sheet-feed scanner for the
archived record scanning project and then buy a flat-bed scanner for occasional use.

Dual-monitor workstations often are used in large-scale scanning operations. The scanning
equipment operator can view two scanned pages simultaneously, or view the indexing
structure and a scanned image simultaneously.
Selecting and Implementing EDMS
Selection
 Although some EHR systems incorporate EDMS functionality, many EHR vendors are
moving away from proprietary EDMS offerings. Instead, they are recommending EDMS
vendors with whom they have worked, to ensure compatibility. Even if your EHR vendor
Section 6 Optimize—Optimization Strategies for Electronic Document Management Systems - 3
offers EDMS functionality, it is advisable to consider other options. If you will primarily be
archiving records for occasional retrieval, you might consider using an EDMS contractor
who can do the job faster and often for less cost than hiring and training your own staff and
buying or even leasing your own equipment. However, if you anticipate scanning a fairly
large amount of documents on a routine basis, you will probably need to acquire the
necessary equipment and software, and determine whether existing staff, additional staff, or
part-time staff can perform the scanning.
 When searching for EDMS vendors online, be sure to set your browser to electronic
document management systems in health care. Several other industries, such as education,
are heavy users of EDMS. Vendors for these industries will not necessarily provide the same
functionality you need.
 Approach the selection of EDMS as you would section of your EHR. Issue a solicitation for a
bid or proposal that describes your needs in detail. If you already have an EHR, identify it so
that vendors can determine compatibility. Describe the volume of documents you have to
scan and their age. This is important for determining the nature of scanning technology, the
amount of storage, and the level of indexing needed (older records will be less likely to be
retrieved, so do not need as much indexing).
 Make sure you are addressing backup storage. You may use a server to store all of the
scanned images, but you should also have either another server at a remote location or, at
minimum, backup CDs stored at a remote location. Rule of thumb: The contents of one fourdrawer file cabinet will convert to one CD.
 If you are soliciting bids from a contractor to perform the scanning for you, determine if
scanning will occur onsite or offsite. If only offsite is offered, you will want to ensure that the
company is fully bonded, and may even want to inspect or require that an inspection of the
facilities to ensure security. You should specify whether you want the paper warehoused for
an extended period of time, warehoused temporarily, or destroyed immediately. Because your
scanned images are accepted in a court of law under the best evidence rule, you will most
likely want to destroy them. However, you may prefer—or the state in which you operate
may require—that paper documents be warehoused for a few months, allowing you can
identify any issues with documents that are missing or were not scanned properly. It is
advisable to check with your attorney before you decide when to destroy the original paper
records.
 If you will be doing your own bulk scanning for archival records, two other considerations
are important:

Space to stage document preparation, scanning, and temporary storage of records
scanned. Some organizations find they do not have adequate space to perform these
functions and need to rent temporary space.

Paper destruction services. You may already use a shredding company to shred
confidential documents. These companies typically supply locked bins in documents
are temporarily held until the bins are full. Then the service comes and puts the bins
into a truck outfitted with a shredder to conduct the shredding at your site. For a
large-scale scanning operation, you may need a locked storage area, rather than
simply bins, to hold the records to be shredded. You should also obtain a manifest of
destruction each time a batch of records is shredded.
Section 6 Optimize—Optimization Strategies for Electronic Document Management Systems - 4
Implementation
It is of utmost importance to ensure that each document has been scanned and indexed properly. Not
only is this necessary because you will be destroying the paper documents, but your users will not
tolerate poorly scanned documents, may have difficulty finding documents. Many users stop
referring to scanned documents entirely if the process is too time-consuming. Unless you use ECMS,
which recognizes the name and/or identification number of a person’s documents, there will be no
way to find a misfiled document except to open and review every document that has been scanned—
a virtually impossible task.
The following are steps to be taken to implement EDMS:
1. If bulk scanning will be performed, ensure space is acquired for staging and temporary
storage. To determine the duration of your space needs, estimate the volume of documents to
be scanned and the time it will take to prepare, scan, and index them
2. Install and test hardware and software. Ideally, find some “typical” documents to scan in
order to test whether each type of potential issue can be addressed by the equipment,
following your policies and procedures.
3. Develop policies and procedures for initial scanning:
a. Document preparation. In this step each document is examined to determine that the
individual’s name is on the front and back (if the back is written on), that
identification information is correct. Remove staples, repair torn or dog-eared pages,
photocopy any documents on card stock that will not go through a sheet-feed scanner,
arrange documents in date order by type of document, and ensure all pages are in the
proper orientation. If any documents are of poor quality, photocopying them while
adjusting the copy contrast (light and dark) may improve legibility. If not, write or
stamp on the document “Poor Quality Original” (PQO) and place it in its proper
location for scanning.
b. Document scanning. This step requires daily review of the scanner itself to make sure
it is calibrated for proper image quality. Once ready, a stack of approximately the
appropriate number of documents should be fanned and inserted into the scanner.
Once each batch is scanned, the documents should be compared with the scanned
images to make all are included. Check to make sure that both sides of two-sided
documents are included and that the sides are in the proper order. Make sure all
documents are properly oriented. If a document is PQO, attempt to improve the
readability by rescanning with different sensitivity settings.
c. Second quality control. Ideally, a different person should perform the same quality
control steps as described above a second time.
d. Indexing. If indexing is a manual process, each document image must be reviewed to
determine if all the information is correct and that the documents belong together.
The documents are then moved to their appropriate folder or a new folder is created.
If the indexing process is automated via barcodes or optical character recognition,
verify that each document is placed in the correct folder. It is helpful to compare the
scanner count with the indexing count and reconcile each batch before moving on to
another batch.
e. Third review and quality control. It strongly recommended that a third quality control
step be performed to ensure that the records in each batch have been scanned and
indexed correctly. Some facilities establish a randomization process to sample
Section 6 Optimize—Optimization Strategies for Electronic Document Management Systems - 5
records for this final review. If more than the specified threshold of errors exists,
another sample is taken. This moves to review of the entire batch if necessary.
4. Develop policies and procedures for ongoing management of scanned documents:
a. If a document is found that needs to be inserted into an already scanned set of
documents or record, this may be done by scanning the document and manually
indexing.
b. If there is a problem with an image and the document can be rescanned from
temporary storage, do so and replace the defective document with the new document.
c. If there is an addendum, correction, or signature that needs to be added to an existing
document that has been scanned and the original is no longer available, establish
policy that reflects how this is handled in the paper record.
i. For an addendum to be referenced from an existing document to a new
document, the procedure in a. above is followed for the new document and
the procedure in c. ii below is followed for the markup of the existing
document.
ii. To make a correction, print out a copy of the scanned image and line out the
error with a single thin line, indicating “error.” Date and sign the correction,
then rescan as above in step a. Delete the original scanned image. If there is
an annotation to be added to a document (such as additional information or
reference to an addendum), print out a copy of the scanned image and add the
annotation on a separate image to follow, dating and signing it with the
current date and the person making the annotation.
iii. Signatures may be added in one of two ways. A signature can be added as
described in c. ii above. Or, it can be added within software that follows an
electronic signature process. This process designates that a review of a
document and intent to sign the document have been performed by an
individual authorized to do so (having applied unique user identification and
password, or other form of secure authentication process, in order to retrieve
and review the document).
5. Develop policies and procedures associated with productivity standards if performing bulk
scanning operations or large-scale scanning on an ongoing basis.
6. Train staff members on the policies and procedures you have created. Training should
include actual scanning under supervision until the person is confident and the supervisor has
observed that all appropriate steps are followed. Monitoring of productivity and quality
control should be stepped up during the training phase.
7. Bulk scanning is a very tedious process. Breaks are needed to avoid repetitive motion issues
and to refresh. It is recommended that not more than 50 minutes of every hour be spent
scanning, with 10 minutes of break time for the person to exercise, use distance vision, or
simply relax.
8. Post-implementation steps should include conducting quality control and encouraging
everyone who retrieves scanned documents to report any issues in image quality or indexing.
Address these by correcting the specific problem, looking for root cause, and taking broader
corrective action if necessary.
Section 6 Optimize—Optimization Strategies for Electronic Document Management Systems - 6
For additional information, see:
Document Management and Imaging Toolkit, American Health Information Management
Association, 2012, available at: http://journal.ahima.org/2012/12/07/document-managementimaging-processes-toolkit-supports-ehr-implementation/
Automated Systems for Child Support Enforcement: A Guide for Electronic Document Management,
2007. (Although geared toward social services, this is an excellent resource for all type of health care
providers.) Available at: http://www.acf.hhs.gov/sites/default/files/ocse/dcl_07_36a.pdf
Fundamentals of the Legal Health Record and Designated Record Set, American Health Information
Management Association, 2011, available at:
http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_048604.hcsp?dDocName=bok
1_048604
Copyright © 2014 Stratis Health.
Section 6 Optimize—Optimization Strategies for Electronic Document Management Systems - 7
Updated 01-01-14