Nirvana:
(in Buddhism) a transcendent state in which there is neither suffering, desire, nor sense of self, and the subject is released from the effects of karma and the cycle of death and rebirth. It represents the final goal of Buddhism.
(in healthcare) complete interoperability
Interoperability:
From tech target: Interoperability is the ability of different systems, devices, applications or products to connect and communicate in a coordinated way, without effort from the end user. Functions of interoperable components include data access, data transmission and cross-organizational collaboration regardless of its developer or origin. Similar to compatibility, interoperability helps organizations achieve higher efficiency and a more holistic view of information.
Complete interoperability (Nirvana) is a main factor in getting people out of paperwork. The good news is that the US healthcare system is marching toward complete interoperability. HealthIT.gov reports on the status, as of 2021, of interoperability at Interoperability and Methods of Exchange among Hospitals in 2021 | HealthIT.gov. In the January 2023 review, it shows the progress towards interoperability that healthcare has made from 2017 to 2021. It notes the percentage of hospitals reporting Electronic Health information available from outside sources:
In all hospitals it grew from 51 to 62%
In Suburban hospitals it grew from 61 to 71%
In rural hospitals it grew from 38 to 48%
In medium to large hospitals it grew from 61 to 72%
In small hospitals of 100 or less beds, it grew from 52% to 63%
Those are all solid growth rates. What’s also interesting is what’s left to do:
38% of all hospitals had documents and data still coming in from non-interoperable sources, so did
29% of Suburban hospitals as well as
52% of rural hospitals and
48% of medium to large hospitals and finally
37% of small hospitals of 100 or less beds
That means a lot of “paper” is coming to the hospital from outside sources. What’s getting in the way of interoperability? Healthcareweekly.com listed 5 reasons in its January 2022 post:
Uncompleted industry-wide measurement standards
Uncompleted health IT interoperability standards
Uncompleted patient identification standards
Organizational resistance to data sharing
High cost of interoperability
I would add as perhaps the most consequential barrier, 6) Lack of IT staff. The lack of IT staff makes interfaces difficult to implement and to maintain. That is why in many health systems, no project requiring IT resources moves to contracting without IT’s blessing and typically, commitment of needed resources.
According to a survey from Gartner, IT executives see the talent shortage as the most significant adoption barrier to 64% of emerging technologies, compared with just 4% in 2020. A lack of talent availability was cited far more often than other barriers, such as implementation cost (29%) or security risk (7%). Talent availability is for 75% of the respondents, the main adoption risk factor for automation.
The jury is still out on whether the IT scarcity is part and parcel to the Great Resignation that followed the COVID pandemic. If it is, perhaps there is reason to hope that the shortages of workers will be short lived.
Conversely, there is a school of thought that believes that is not the case as demographics in the US are shifting. Experts note that our population growth is the lowest in history. Millions of baby boomers, the generation that first worked in computer technology, have retired in 2020 and later, highlighting why there is such a problem in finding IT employees.
It appears that most of the six barriers noted above will be removed through government intervention. Though the two that will be difficult to remove from the list are high cost of interoperability (especially where there are many document and data sources that have low volume) and lack of IT staff.
So what is a HIM leader to do? There are three options:
Process those documents coming from non-interoperable sources manually in-house.
Outsource those documents coming from non-interoperable sources to a third party.
Implement an Optical Character Recognition (OCR) based document and data processing software solution.
Process those documents coming from non-interoperable sources manually in-house.
Manual in-house processing of documents is the default solution. It has been since the emergence of electronic medical records when interfaces just didn’t exist at any level. Manual in-house processing requires the fewest technical requirements with costs that are predictable. As volume goes up, you add FTEs and cost goes up. As volume goes down, you remove them and cost goes down. However, manual processes have a few notable problems:
It creates a fragmented infrastructure
Reliance on a single user or another layer of quality assurance
Operational inefficiency is low
It’s hard to scale quickly
It has greater security risks
It’s noted for poor productivity
The highest cost solution
Outsource those documents coming from non-interoperable sources to a third party.
Typically, outsourcing will have a more favorable cost position than manual in-house processing. The costs of outsourcing are predictable on a cost per page or data element basis and, if you know your document page or data volume, on a total cost basis as well. However, you have to be willing to live with the direct control of the document processing moving to the third party. You’ll have to rely on that third party to maintain compliance, drive accuracy, and the timing of delivery.
If the third party utilizes OCR workflow software, there will be higher fixed start-up costs as IT will have to be more involved. However, if the third-party vendor uses software, it may be easier to drive compliance, accuracy, and timing than if the vendor uses a manual process only.
Implement an Optical Character Recognition (OCR) based document and data processing software solution.
OCR is a technology that recognizes text within a digital image. OCR based document and data processing software takes the editable text file and, in varying levels of sophistication and capabilities, applies algorithms, machine learning, and natural language processing to:
Classify the type of document.
Index the document to a patient record in the EHR.
Extract discrete data to be placed in data specific elements a patient record in the EHR.
Typically, OCR based document process software has the lowest cost per page or cost per data element of three options. It drives accuracy, compliance, and timeliness. Control also remains in the hands of the health system HIM Director. This solution will get you as close as possible to a “People not Paperwork” environment.
Detractions are that it takes 3 – 5 months to implement and, though minimal is scope, some IT resources are required.
Cost
After you’ve taken into consideration the benefits and detractions of each of the three solutions, cost needs to be considered.
As a general rule, the cost of manual processing in-house has the highest cost. Mostly because it is labor intensive. Outsourced processing is generally the second highest cost solution. OCR based processing is generally the least costly of the three alternatives to interoperable solutions (when sources of documents or data are relatively low volume and the number of individual sources is high). Interoperable solutions become the lowest cost solution when source of documents or data are at relatively high volumes.
If you want to determine what solution is the lowest cost solution, the calculation is relatively easy:
Vendor solution total cost for a set amount of document pages divided by the number of document pages to be processed. For example, a health system has 4,000,000 pages being processed annually. If their cost of software and implementation is $358,000. The vendor’s cost per page is $0.10 ($358,000 / 4,000,000). That number can be compared to other options to determine which option makes sense from a price perspective.
If you’re trying to make a decision about moving from a manual in-house process to another processing option, the calculation is present labor costs divided by the number of pages being processed compared to the total of labor costs associated with the solution option you’re comparing it to plus the cost of the option divided by the number of pages being processed.
Present price per page:
$2,106,000 present wages and benefits for 45 FTEs at $18.00 per hour plus $4.50 per hour in benefits working 2,080 hours per year divided by 4,000,000 pages annually equals $0.53 per page.
Future price per page:
Using the same numbers as before: ($358,000 for the implementation costs of the OCR software solution plus $380,859 for the new labor costs) divided by 4,000,000 pages being processed which is $0.185 per page for the first year and $0.165 for each year afterwards (implementation fees are a one-time cost).
That change translates into a 209% annual average rate of return over 4 years for changing from a manual inhouse process to an OCR based software process.
The point here is that everyone should look at the four processes, understand what the benefits and detractions of each are. Understand what the financial value brought by each is and make a decision that is right for you and your health system.
The contents of this blog was presented earlier this week in a longer form content in a webinar with Interlace Health. The webinar is free, eligible for AHIMA CEUs, and can be found here: On-Demand Webinar: People Over Paperwork with Extract Systems (interlacehealth.com)
About the Author: Norm Kruse
Norm is a Business Development Manager with experience in Healthcare and Telecommunications technologies. He earned his BS – Business Administration at Winona State University and his MBA – IT Concentration at the Carlson School of Business at the University of Minnesota. Technology applied to workflow design is a focused area of interest.