by Deborah Kohn, MPH, RHIA, FACHE, CPHIMS
Only in recent years has the widespread acceptance and use of computer systems and Internet-derived technologies allowed HIM departments of all types and sizes to be physically untethered from their organizations and exist virtually. From a technical perspective, an HIM department function can be performed remotely if:
- the department function is completely automated by an information system;
- there is no need to access any line-of-business, “physical” object within the HIM department, such as the paper medical record, the patient, or a medical device; and
- there are adequate, deployed networking technologies (including the Internet) for access purposes.
When all HIM department functions can be performed remotely, the entire department can exist as a virtual department.
The following descriptions (in alphabetical order only) review some of the myriad computer systems and technologies that are or can be deployed to support virtual HIM department functions and processes.
Automated Speech Recognition Technology
ASR technology (or speech recognition technology) allows a computer to “transcribe” spoken words by comparing their sounds to a database of word pronunciations and then rendering the matching word on the screen. Today’s speech recognition technology can approach 99 percent accuracy rates with training.
Most speech recognition technologies contain semantic tools savvy enough to determine whether a word is a noun or verb, and they offer good guesses at punctuation. By itself, however, ASR technology has no comprehension of the words it renders. It can replace the keyboard but not the human brain behind it.
There are two types of ASR technology systems. An orders-based speech recognition technology system is one that primarily is used by radiology, pathology and other related service departments where ordered test results are dictated. An encounters-based speech recognition technology system is used primarily by HIM and related service departments where encounter information is dictated.
The technology systems can be deployed in several ways. One is front-end clinician editing. The key advantage of this type of deployment is that immediate speech authentication eliminates transcription turn-around times. A disadvantage is that many clinicians cannot tolerate the (typically) time-consuming learning curve.
Another deployment method is full or partial back-end transcriptionist editing. The key advantage is that dictators typically are not aware that their dictation is being routed through the speech recognition technology system and subsequently edited on the back end by transcriptionists or editors. One disadvantage is that even the best systems deployed in this way include turn-around times.
Digital Signature Technology
A digital signature identifies the author or responsible party who takes ownership of and attests to the information contained in a record entry or document. There are several types of digital signature technologies that enable virtual HIM departments.
Narrowly defined, electronic signatures (or e-signatures) require the application of a password or other form of electronic authentication to an electronic document. E-signatures can be strengthened with the addition of a token such as an ID card or a biometric device to the authentication process. Consequently, the term often is used to describe the signing of dictated and transcribed reports from a text or transcription system or ancillary department information system (e.g., a radiology information system) and orders from a computerized provider order entry system.
Digital signatures are cryptographic signatures (i.e., encrypted using digital keys) that authenticate the user, provide nonrepudiation, and ensure message integrity. Digital signatures are the strongest form of digital signature technology because they are protected by a type of “tamper-proof seal” that breaks if the content were to be altered.
Digitized signatures are applied images of handwritten signatures to medical record reports and documents. Digitized signatures are the weakest forms of digital signature technology because someone who acquired copies of the signature image could forge electronic documents.
Digital Text (Transcription) Technology
Thankfully, digital text or digital transcription technology has been used in HIM departments since the early-to-mid 1980s. Most began as simple text editing systems-programs that enabled users to create, edit (e.g., cut and paste, word wrap), and print basic text files.
These systems evolved into word-processing systems providing hundreds of text file formatting features (e.g., font specifications, headers and footers, spell checkers) that enabled users to manipulate and format documents in more sophisticated ways. With the onset of a plethora of networking technologies during the 1990s, digital transcription was the first HIM function to be performed remotely. Today, it is performed internationally.
Digital Voice (Dictation) Technology
The ability to create and store digital audio files (e.g., voice dictation) also has been used by clinicians and HIM departments since around the mid- to late 1980s. Today many different digital audio formats and software systems are used to create, store, and manipulate these files.
With the onset of sophisticated networking and telecommunication technologies beginning in the 1990s, digital dictation became an early HIM function to be performed remotely. Today a clinician can dictate using almost any type of telecommunication device from almost any place in the world.
Electronic Document Management Systems
Since records and documents are the mainstay of HIM departments, electronic document management systems (EDMSs) play significant roles in HIM departments. The systems allow many HIM Department functions to be performed remotely.
An EDMS is a computer system consisting of many component technologies that enable healthcare businesses to use documents to realize significant improvements in work processes. Such component technologies include (but are not limited to) the following.
Automatic Identification Technologies
Automatic identification technologies include bar codes, intelligent character recognition (ICR), intelligent document capture (IDC), optical character recognition (OCR), and optical mark recognition (or mark sense).
Bar codes are machine-readable representations of data, typically dark ink on a light background to create high and low reflectance to add scanning. Originally, bar codes stored data in the widths and spaces of printed parallel lines. However, today bar codes also come in patterns of dots, concentric circles, and text codes hidden within images.
Bar codes are read by optical scanners or scanned from an image by special software. In HIM department EDMSs, bar codes are used to eliminate the manual indexing of document type, patient name, provider name, medical record number, and other information, as well as medical record “separator” sheets during the digital scanning process.
ICR is a more specific type of OCR, allowing different styles of handwriting to be learned by a computer. Most ICR software includes a self-learning “engine” (i.e., a neural network) that automatically updates the recognition database for new handwriting patterns. In healthcare EDMSs, ICR is used to recognize information such as handwritten orders, progress notes, and signatures in documents.
OCR is the electronic translation of analog, typewritten, or printed text into machine-editable text. Early OCR systems required system training to read specific typed or printed fonts. Today, systems with a high degree of recognition accuracy for all fonts are common. Some systems are capable of reproducing formatted output that closely approximates the original scanned page, including images, columns, and other nontextual components. In healthcare EDMSs, OCR is used primarily to recognize printed text on claims forms.
Mark sense is the process of capturing data by requiring a page image to have high contrast and an easily recognizable shape. Mark sense is distinguished from OCR by the fact that a recognition engine is not required. That is, the marks on a page are constructed in such a way that there is little chance of not reading the marks correctly. One of the most familiar applications of optical mark recognition is the use of checkboxes on multiple-choice question examinations. In healthcare EDMSs, mark sense often is used for physician office super bills and charge tickets.
Computer Output to Laser Disk (COLD) (or Enterprise Report Management [ERM]) technology is a component technology of an EDMS that stores computer output to and indexes computer output on digital storage media. Such computer output consists primarily of computer-generated reports (e.g., electronic health record system reports, invoices, management reports, laboratory information system test result reports, and word-processed reports) whose data are report-formatted. Once stored, the reports can be retrieved, viewed, printed, faxed, or distributed via the Internet.
Document Management Technology
Document management technology is a component technology of an EDMS that controls and organizes documents. This includes document assembly, document version control, document check-in/check-out, and document security.
Document assembly allows medical record documents to be automatically retrieved in the “correct” order, based on predefined, user-specific rules and tables.
Document version control allows documents to be automatically assigned version numbers. For example, this might include daily laboratory test result reports (version 1) versus cumulative summary laboratory test result reports (version 2); preliminary radiology procedure result reports- unsigned (version 1) versus final radiology procedure result reports-signed (version 2); and transcribed operative reports (versions 1 and 2), versus signed transcribed operative reports (version 3), versus amended transcribed operative reports (version 4). Typically, only the most recent or last document version is accessible for viewing.
Document check-in and check-out allows users to collaboratively review and edit shared documents without concern that someone else might be simultaneously updating the same document. It also allows users to view all entries made to the shared document. Clinical teams that author progress notes are an example of sharing documents using document check-in and check-out capabilities.
Document security consists of all the technical document tools to protect, control, and monitor document access (e.g., unique user identification or authentication, audit trails, automatic log-offs, and biometric identifiers) and prevent unauthorized access to documents transmitted over a network.
Electronic Document Imaging Technology
Electronic document imaging technology is a component technology of an EDMS that captures (via scanning, faxing, or automatic identification technologies), stores, and retrieves documents regardless of original format. Because HIM departments have worked with massive amounts of analog medical record documents for so many decades, they currently use this EDMS component the most. As such, often this EDMS component technology is synonymously and incorrectly used to describe an EDMS.
However, when all internal and external medical record forms, notes, letters, reports, and messages are generated, stored, and distributed electronically, the use of this EDMS component technology will be drastically reduced, and the other EDMS component technologies will be used more frequently.
Forms Processing Technology
Forms processing technology accepts scanned forms and extracts data from the boxes and lines to populate databases. Because medical records consist of hundreds of forms, this EDMS component technology has profound significance for healthcare organizations.
Records Management Technology
Records management technology identifies, retains in a secured repository, provides controlled access to, and destroys records in accordance with predetermined retention schedules. HIM departments always have made astute decisions regarding which analog health records to keep and how long to keep them. Today, HIM Departments are creating and maintaining electronic record retention and disposition schedules using automated records management functions, including electronic record classification, retention calculations, and preservation formats.
Workflow and Business Process Management Technology
Workflow and business process management technology automates business processes in whole or in part. A business process is a logically related set of workflows, work steps, and tasks that provide a product or service.
Specifically, EDMS workflow passes documents, information, or tasks from one participant to another for action according to a set of business rules. The use of this important technology significantly contributes to the success or failure of the transition to and on-going expansion of virtual HIM departments. This is because workflow technology should be deployed for every business process work step and task in the HIM department-from record creation to concurrent coding to discharged chart analysis and completion to release of information to, ultimately, record destruction.
Health 2.0 Technologies
Health 2.0 technologies are “social media” or Web 2.0 technologies adapted to healthcare uses. Social media technologies can be defined as online technologies and applications used to share information, opinions, expertise, insights, and interests using text, images, audio, and video in a participatory environment.
All Health 2.0 technologies share common characteristics, such as participation, openness, conversation, community, and connectedness. There are a plethora of Health 2.0 technologies that include the following:
Blogs began as online journals kept by individuals. They have evolved into opinion, insight, and news sources. They are typically simple to use, and the software is often free. Virtual HIM departments can use blogs for communication purposes or, for example, as remote transcriptionist journals logging system problems, downtimes, and other shared notes.
Social networks, such as Facebook and MySpace, connect friends or contacts to communicate and share content. Like blogs, social networks can be used by virtual staff such as coders for communication purposes and to build a sense of online community.
Content communities, such as AHIMA’s Communities of Practice,consist of groups of people with like interests who come together online to share particular content. As such, content communities, like social networks, can be used by all or some of the employees in virtual HIM departments for communication and information-sharing purposes.
Wikis, such as Wikipedia, are collaborative Web sites that allow people to collectively add or edit content. Virtual HIM departments can use wikis to develop organization-specific materials such as pharmacy lists or information system business rules.
Podcasts are audio or video files typically available by subscription and listened to or viewed online or downloaded to an MP3 player. They are a specific form of content sharing that often involves feedback. Podcasts can be used by virtual HIM departments for training purposes, department meetings, and similar activities.
Interface technologies define the communication between two entities, such as two software applications (software interfaces), two hardware devices (device interfaces), or a human and a computer (user interfaces). Communication between two software application databases is handled either through a point-to-point interface or through an interface engine. However, screen scraping and scripting technologies can also interface systems.
Screen scraping is used to bridge older, “legacy” systems that use older input and output devices and user interfaces with newer devices and user interfaces. This allows the logic and data associated with the legacy programs to be used on the newer systems. Typically screen scraping is used to bring data out of one application and into another.
Scripting is a programming language that is interpreted by another program while the program is running. Scripting can be embedded in Web pages to add functionality. Scripting typically is used to push data back into one application from another.
Interface technologies are critical to maintaining virtual HIM departments because they ensure successful communication among the various line-of-business information systems. Organizations devote significant time and resources to developing and maintaining interfaces.
The Internet supports a plethora of derived technologies such as the Web, intranets, and portals that have become the backbone of many organizational communication systems.
Intranets are “private” Internet networks. The servers are kept inside a firewall so that the general public cannot access the network. Intranets address internal business needs within a secure environment, and include everything from message boards, employee handbooks, policy and procedure manuals to cafeteria menus, newsletters, and directories-all of which can be accessed by staff in virtual HIM departments.
Portals are secure Web-based gateways for information, transactions, services, and products within an organization, industry, or industry segment. They are personalized to meet the needs of end-users based on their roles and preferences, such as physician portals, nurse portals, patient portals, employee portals, and executive portals.
Natural Language Processing
Natural language processing (NLP) is a form of artificial intelligence. By applying computer-based reasoning, semantic rules and domain-specific language models, NLP can grasp the meaning behind the words and their relationship to each other in context.
The convergence of ASP and NLP helps tethered HIM departments transition to virtual ones. Together the technologies bridge the richness of descriptive clinical documentation and structured data for data mining, clinical decision support, and quality assurance tasks.
Computer networks are multiple connected computers that communicate over a wired or wireless medium, sharing files, data, and other resources. The size and scalability of any network is determined by the physical medium of communication and the software controlling the communication.
Only ten years ago it was prevalent for healthcare provider organizations to house computer networks and equipment in one data center using a local area network (LAN) that connected the computers, or nodes, in the network. While centralized data centers and LANs are still common, wide area networks (WAN) that span entire cities or states are more common. Virtual departments are likely to use WANs.
Virtual private networks (or VPNs) use public “wires,” such as the Internet, to transport data and connect the organization’s network nodes. VPNs use encryption and other security measures to ensure that only authorized users can access the network and that the data shared there cannot be intercepted. With proper authentication, remote workers can “tunnel” into the organization’s local network to work with the files and applications housed there.
Deborah Kohn (firstname.lastname@example.org) is principal of Dak Systems Consulting in San Mateo, CA.
Note: An abbreviated version of this story appeared as a sidebar in the feature “Virtual HIM,” Journal of AHIMA 80, no. 3 (March 2009): 38–42.
Kohn, Deborah. "How Information Technology Supports Virtual HIM Departments" Journal of AHIMA 80, no.3 (March 2009): Web extra.