Stopping the record merry-go-round: new technology allows an organization to more efficiently manage patient records.

Tarzana Treatment Centers is one of the largest providers of integrated behavioral healthcare services in southern California. Its approximately 600 employees deliver a broad range of inpatient, outpatient, and residential services (including primary medical care) at nine sites in Los Angeles County. More than 15,000 patients pass through our doors annually.

As Tarzana's patient volume grew, so did the volume of medical records. Efficient record management was a growing concern, especially the process of chart completion (the actual signing, sealing, and dating of the chart that forms each patient's legal health record).

Tarzana did have a clinical electronic medical record (EMR) system, providing a complete clinical profile of patients, but the organization still had paper records. This led Tarzana to explore and ultimately implement electronic legal health record work-flow technology to enhance record access, thereby streamlining and speeding up the completion process as Tarzana continued to replace its paper records.

A legal electronic health record (EHR) became the organization's documented set of information for each patient encounter, a compartment of the entire patient database that serves as the legal business record for the organization. The legal EHR supports patient care decisions and payment. It also documents services as legal testimony on the patient's illness or injury, reaction to treatment, and caregiver decisions.

A Record Merry-Go-Round

Before 2007, record completion (the process of finalizing and signing off on the complete record for legal, billing, reporting, and quality assurance purposes) was a major issue for Tarzana. As in any behavioral healthcare organization, many staff members needed to sign off on one record, including physicians, nurses, interns, social workers, counselors, and dieticians--all of whom had to document the care they provided.

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Each day Tarzana's health information management (HIM) department faced the recurring tasks of notifying employees of incomplete records, pulling those records when staff arrived at the HIM department to complete them, refiling the records, and then accessing them again for additional staff members. This record merry-go-round consumed close to 70 hours of staff time per week. As is typical for many behavioral healthcare organizations, a sizable percentage of Tarzana's patients return for visits and/or are seen at multiple locations, and tracking down existing charts for subsequent encounters was adding to the resource drain.

Space also was a growing concern. Paper records were consuming more than 2,800 linear feet in an organization constantly seeking more space for clinical activities. California requires healthcare organizations to retain patient records for seven years, and Tarzana was creating new charts significantly faster than it could destroy old ones. In addition, natural disasters relatively common in the area, such as earthquakes, floods, and fires, were a perennial worry given that records were stored at all nine locations as well as at an off-site storage facility.

The final issue compelling Tarzana to seek an answer to its record management issues was its rather unique stance, with one foot in the not-for-profit sector and the other in the private insurance industry. The organization has a private insurance business that addresses the needs of managed care and private insurance companies. The ability to respond rapidly to the information needs of both worlds demanded an efficient approach to medical record handling and storage.

Initiating Change

Tarzana began looking for technology that would digitize its existing paper records and electronically store these images. Simultaneously, the organization sought to streamline the process of accessing and completing these records. The goal was to enable employees with appropriate access privileges to work with charts wherever and whenever they wanted, allowing viewing and completion as well as e-signature capabilities. The digital images needed to be alterable so that missing information (such as signatures, dates, or notes) could be added to complete the record.

Tarzana selected a legal EHR technology vendor (eWebHealth) for its ability to fully meet these needs as well as ensure a level of record security particularly essential in behavioral healthcare. The vendor's HIM expertise was a critical component to ensuring a smooth implementation. Together Tarzana and the vendor mapped the paper work flows, scrutinizing processes for improvement opportunities and then carefully applying the new medium. This HIM knowledge also served Tarzana well during the staff training phase.

Since the legal EHR system went live in September 2007, the HIM department has scanned every new chart postdischarge as well as its chart backlog to minimize running parallel paper and electronic processes. The organization has been working to convert each chart into electronic format (data or image). When patients return for services, their old paper records are pulled and digitized as well, creating image files that have descriptions associated with them that can be searched for or edited. Once scanned, the paper versions are securely discarded. Admission, discharge, and transfer information is supplied via an interface with Tarzana's EMR.

Systematically eliminating paper charts will allow Tarzana to gradually consolidate all of its remaining paper records in fewer locations until Tarzana is operating in a paperless environment. As the volume of paper declines, Tarzana reduces the physical risk to the charts while it reclaims storage space for revenue-generating clinical uses. Tarzana no longer uses an off-site storage facility; HIM staff are now centralized at one location; and staff at any site have electronic access to any record no matter where a patient was treated.

Real Results

Tarzana employees have been enthusiastic about the legal EHR and its labor savings. Clinical staff can easily look up critical medical information in a patient's chart at any time, from anywhere, without chasing down the record from another department or location. With a few key strokes, the HIM department can notify clinicians of their various chart deficiencies. In turn, clinicians can complete their work--including record signature--from wherever they have Web access.

HIM staff no longer have to track the minutiae of chart deficiencies. If a physician signs only two of three charts on his/her electronic work list, the incomplete chart will stay on the list until signed, without a HIM staff member needing to intervene or even be aware of what has been done and what has not. Yet the HIM staff can run chart deficiency reports by provider or location.

Patient accounts employees also can access patient charts electronically. When documentation is required for reimbursement or other purposes, employees have quick access to the information. Along with making charts more accessible, the technology enables Tarzana to maintain much tighter control over who views patient records and which parts are seen--important capabilities for protecting patient information's confidentiality.

Employees have different levels of access to charts, depending on their responsibilities. A robust auditing feature enables authorized employees to track who has viewed a patient record, a deterrent to employees who may be tempted to overstep their access rights. Because Tarzana does care for high-profile patients as well as its employees, the new system's ability to lock down records, so that only someone with the appropriate clearance can see them, is extremely important.

Looking to the Future

The HIM department anticipates that in the coming months it will be able to more easily fulfill outside release of information (ROI) requests by adding a component to the system and possibly complete quality assurance activities, something that the clinical EMR is not designed to do.

Tarzana is exploring the use of the technology to facilitate audits from county programs with which it contracts. Auditors typically arrive unannounced with a lengthy list of charts to audit. With the new system, HIM staff can efficiently collect the charts with just a few mouse clicks and with minimal disruption to their daily work. If an auditor is looking into only a particular episode, Tarzana no longer faces the choice of providing the whole record or taking the time to break down the record into the episode of interest. Instead, staff can select the relevant episode and grant access to only that information.

Implementing supplemental legal EHR technology was necessary for Tarzana to remain competitive. With a significantly improved ability to manage its medical record work flow, Tarzana can spend less time and money chasing records and focus instead on delivering high-quality patient care.

Jim Sorg, PhD, Director of Information Technology at Tarzana, can be reached at jsorg@tarzanatc.org. Tim Swaney, Health Information Management Supervisor at Tarzana, can be reached at tswaney@tarzanatc.org.

BY JIM SORG, PHD, AND TIM SWANEY