Cleaning Up Document Imaging’s Image

Since the late 1980s, when one of the technologies of electronic document management systems (EDMSs), document imaging technology (a.k.a., document capture technology), first was implemented in U.S. healthcare provider organizations to manage (i.e., digitize) the organizations’ massive amounts of medical, financial, and administrative analog documents, many health information management (HIM), healthcare information technology, and other related professionals did not understand that document capture technology is NOT the only technology of an EDMS.   Other EDMS technologies include:

Automatic IdentificationTechnologies – EDMS technologies that allow documents to be automatically identified.  The following are examples of EDMS automatic identification technologies:

  • Automatic / Intelligent Document Recognition (ADR/ IDR) recognizes the layout and content of generic form types.  In healthcare organization EDMSs, ADR / IDR is used to recognize digital and analog form categories.
  • Bar codes are machine-readable representations of data, typically dark ink on a light background to create high and low reflectance which is converted to 1s and 0s. Originally, bar codes stored data in the widths and spaces of printed parallel lines.  Today, bar codes also store data 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, and medical record number, etc., as well as medical record “separator” sheets during the digital scanning process.
  • Intelligent Character Recognition (ICR) allows different styles of hand printing and hand writing 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 organization EDMSs, ICR is used to recognize documents’ hand printed / hand written numbers or abbreviations on analog orders, in analog progress notes, etc.
  • Optical Character Recognition (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, OCR has a high degree of recognition accuracy for all fonts.   Some systems are capable of reproducing formatted output that closely approximates the original scanned page including images, columns and other non-textual components.  In healthcare organization EDMSs, OCR is used primarily to recognize the printed text on claim forms.
  • Optical Mark Recognition (OMR or Mark Sense) is the process of capturing data by requiring a page image to have high contrast and an easily-recognizable shape.   Mark sense (OMR) 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 #2 pencils on paper-based, multiple choice-type question examinations.  In healthcare organization EDMSs, mark sense often is used for physician office analog super bills and charge tickets.

Enterprise Report Management (ERM) technology (formerly known as COLD: Computer Output to Laser Disk) – an EDMS technology that stores “computer output” to – and indexes “computer output” on – digital storage media.  Once stored, the computer output can be easily retrieved, viewed, printed, or distributed.  Today, “computer output” consists primarily of batch-generated computer reports with data that are report-formatted.  Electronic Health Record (EHR) batch-generated computer reports include EHR system bills / invoices and management reports.

Document Management (DM) technologies – EDMS technologies that control and organize documents.  The following are examples of EDMS DM technologies:

  • Document Assembly allows documents to be automatically retrieved in the “correct” order, based on pre-defined, user-specific rules and tables.
  • Document Version Control allows documents to be automatically assigned version numbers.  For example, this includes daily laboratory test result reports (version 1) vs. cumulative summary laboratory test result reports (version 2); preliminary radiology procedure result reports – unsigned (version 1) vs. final radiology procedure result reports – signed (version 2); transcribed operative reports (versions 1, 2) vs. signed transcribed operative reports (version 3) vs. amended transcribed operative reports (version 4).  Typically, only the most recent or last document version is accessible for view purposes.
  • Document Check-in / Check-out allows users to collaboratively review / edit shared documents without concern about who might be simultaneously updating the document and to view all the entries made to the shared document.  Clinical teams that author electronic progress notes is an example of this important DM technology.
  • Document Security consists of all the technical document tools to protect, control and monitor document access (e.g., unique user identification / authentication, audit trails, automatic log-offs, and biometric identifiers) to prevent unauthorized access to documents transmitted over a network.

Digital signature management technology – an EDMS technology that offers both signer and document authentication. Signer authentication is the ability to identify the person who digitally signed the document. The implementation of the technology is such that any unauthorized person will not be able use the digital signature. Document authentication ensures that the document and the signature cannot be altered (unless by means of showing both the original document and the changed document). As such, document authentication prevents the document signer from repudiating that fact.

Forms Processing (a.k.a., Electronic Forms Management, Automated Forms) technology  – an EDMS technology that electronically delivers paper forms for printing and completion, accepts scanned paper forms and extracts data from the boxes and lines on the forms to populate databases, and utilizes eForm templates — that look like paper forms — for online data entry / data collection.   Because patient medical records consist of hundreds of forms, even with EHRs, this EDMS component technology is important for healthcare organizations.

Workflow / Business Process Management (BPM) technology – an EDMS (or any other type of information system) technology that is the EDMS’ (or other information system’s) most important component technology!   BPM technology automates business processes, in whole or in part.    EDMS workflow / BPM technology passes documents, information, or tasks from one user to another for action according to a set of business rules.

Today, many healthcare organizations use the EDMS’ document capture component technology more than the other EDMS component technologies.  The primary reasons include the need to:

  • continue to convert existing analog documents into digitized documents
  • maintain a legal archive from which to generate the electronic document presentation as proof for exception and dispute handling (i.e., by extension, the need to have the document presentation for legal purposes and NOT an informational statement or data representation of the document, which, unfortunately, remains too common the output in today’s electronic patient record systems).

However, when ALL internal and external documents, forms, notes, letters, reports, and messages are digitally-generated, stored, and distributed, the use of the EDMS document capture component technology will be drastically reduced, perhaps eliminated, and all the other EDMS component technologies will be used frequently.