Document Management Helps Cleveland Clinic Take Epic One Step Further

Edited by Jennifer Dennard, Health IT Outcomes

Systemwide integration of a document management solution helps Cleveland Clinic derive more value from its EMR.

Ninety-two-year-old Cleveland Clinic is a nonprofit, multispecialty academic medical center offering more than 4,450 beds systemwide. Its staff includes more than 3,000 physicians and scientists and 1,785 residents and fellows in training, who handle more than 5.1 million patient visits each year. Dr. Robert White, associate chief medical information officer, explains how enterprise document management has improved workflows across the organization and helped the clinic realize more value from its EMR.

Q: What motivated Cleveland Clinic to look at implementing an enterprise document management solution?

Dr. White: We realized, after implementing Epic at our ambulatory clinics in 2006, that an EMR doesn’t completely eliminate the need for paper forms. Current technologies just aren’t there yet. ”Paper-lite” is the best you can hope for, even with an EMR. We also realized that native EMRs are not fully capable of handling unstructured data such as images from ophthalmology, EKGs, and sleep study data.

Our physicians found themselves with this great new EMR, but they were still spending time searching for files outside of the EMR that were scattered all over the place. We knew at that point we needed to do more than just manage paper. We needed to be able to manage the paper and other unstructured data and put it in locations that made the most sense for easy physician retrieval.

We also knew we had to resolve this workflow issue, so we decided to seriously look at augmenting that technology with a document management solution across our entire system. Epic even suggested we adopt a document management solution, though they were careful not to recommend a particular one. They have not yet developed their own because they have good partners like Hyland that do that for them. While it was pretty much a foregone conclusion that we needed to do it, it was up to our due diligence to select the document management solutions vendor.

Q: What factors influenced your selection of a document management solution, and what was the timeline for implementation?

Dr. White: Prior to Cleveland Clinic, I was CMIO at a smaller, multihospital system in Illinois that used Epic and Hyland Software OnBase document management solution. The fact that Epic has close ties with Hyland Software, and I was already familiar with the OnBase solution, greatly influenced our decision.

We selected OnBase and implemented it across the Cleveland Clinic system in 2007, right around the same time we were bringing our hospitals up on Epic. I was already aware of the organizational and governance processes necessary to successfully implement OnBase and integrate it into Epic. That experience helped my team at Cleveland Clinic set up standards around naming documents, where they lived, and at what level in the system. That part of the process was painful, but necessary.

Putting standards in place helped our physicians get past the problem of “if it’s not easy to find, it doesn’t get found.” Our job in preparing to go live was to make sure that documents got into the medical record and were found in a logical place for our physicians. The ease with which OnBase enabled us to configure all of this data really helped to make this a quick process. We now have several thousand employees using OnBase on a daily basis across all of our facilities, as well as any physician who provides care at one of our facilities.

Q: What benefits did Cleveland Clinic realize as a result of implementing a document management solution?

Dr. White: It has helped tremendously with simple document management. We’ve been able to successfully integrate the output of several information systems directly into Epic utilizing OnBase. These systems include Lawson; our Sunquest labs system; Siemens Invision for patient management and Siemens Signature for billing; McKesson Star for revenue cycle; GE Muse for cardiology; Philips Tracemaster for EKGs; Topcon for retinal eye photos; Nihon Kohden for EMGs; our admitting, discharging, and transferring system; and our anesthesia record-keeping system. That’s a huge volume of information.

It has also helped with more efficient retrieval of files from within the EMR. Our physicians now know exactly where different types of data live within the EMR and are able to pull that data in a much more efficient manner. There are some documents such as EKGs that many physicians, from primary care to specialty, may want to use. Then there may be documents that only a small percentage of physicians are going to want to see because they’re subspecialized. Retrieval and the ability to get at those various files has become much more streamlined.

The physicians certainly appreciate it. You create wins for them, specifically when you don’t hear any concerns from them. When you don’t do something right, you hear it all the time. We think that not hearing from them or hearing an occasional positive comment has been an enormous win.

We’ve also seen benefits on the nonclinical side, such as in the HIM department. The configurability and the ability to bring documents in and do different things with them depending on the user’s need have been downstream benefits for a number of departments. We’re able to scan in and integrate histories and physicals from other information systems to be used for our surgical patients. OnBase manages all of that electronic capture and placement within Epic; that’s really been pretty slick. It all comes down to one common denominator: It’s got to come into Epic. That’s the bottom line source of truth.

Regarding a measurable benefit, usage is as much data as I can give you. We now include the OnBase solution as part of the standard IT package we deliver to any office in which we go live. That being said, 100-percent utilization by our staff is a pretty good measurable benefit, in my opinion.

Q: What implementation best practices and lessons learned would you recommend to other providers looking to adopt a document management solution?

Dr. White: The biggest things to realize are that you absolutely need a document management solution, and you need physician governance around where the clinical documents live within that solution. In my prior role, I insisted we have a clinician involved with the decision-making process. That ultimately got expanded into a larger physician governance effort. Physicians are trying to do their work as efficiently as possible. If they can’t easily find a document, it’s as if it’s not there. Their input is essential to optimizing a document management solution for an organization’s unique needs and workflows.

I’d also recommend getting in touch with other users of the document management solution you’re considering. Hyland has been very helpful about letting us know how other organizations are using their system and then putting us in touch with them for further discussion. It’s really helpful to have that kind of insight when making an enterprise IT implementation and purchasing decision. You’ll end up making the vast majority of your physicians happy if you keep those three things in mind — though they might not let you know it.