Saving Costs and Improving Staff Performance in Document Imaging

The mantra of do more, spend less has rung out loud and clear in healthcare for many years now. The enactment of legislation, reimbursement for quality versus quantity, and pressure from external auditors has exacerbated the conflict between increased production and decreased expense. The burden to reduce operational costs is felt by every department director and service line executive.

However, analyzing the entire healthcare enterprise for cost-savings measures is a daunting task. It has been said that the only way to eat the elephant is one bite at a time. So in this article, we will begin with the most important “bite” for ADVANCE readers – the health information management department, and in particular, the costs associated with document imaging.

While we continually hear about the goal of going paperless, we have yet to see widespread success in achieving this utopia. The fact is that almost all healthcare organizations continue to operate in a hybrid world of part paper and part electronic. Paper documents remain a crucial component of the medical record, even within the most highly automated provider organizations. Document imaging and the human resources necessary to convert paper information into digital images are not going away anytime soon.

The scanning or document conversion function is most typically housed within the HIM department and will be for the foreseeable future. The key for HIM directors is to ensure the process is effective and efficient.

Common challenges in document conversion
IOD Inc., Green Bay, Wisc., conducted a brief survey of HIM directors managing the document conversion process. Directors were asked about common problems in this area. (See Table 1.)

Table 1: Commonly Reported Problems with Document Conversion


    Poor quality images

    Documents incorrectly identified and indexed

    Patient, account number, date of service, etc. are entered incorrectly

    All pages are not captured

    Mixed patient records


    Lack of routine maintenance resulting in degraded performance

    No service agreement, scanner goes down

    Improper handling of scanner resulting in damage

    Wrong sizes and types of scanner for goal

    Failure of interface with imaging systems and the EHR

    Turnaround time and cost

    Slow turnaround time from paper to images available in EHR

    Loose documents post-discharge require manual handling

    Staff burnout, employee turnover

    Escalating system costs: hardware, software and maintenance

Of the pain points noted, there are three common areas that HIM directors must carefully measure to keep costs under budget and make strategic, data-driven decisions about document conversion staffing. These areas are quality, timeliness and costs.

Scan quality has direct impact on patient care and the reimbursement a facility receives for the services provided. The timeliness of the operation, or turnaround time (TAT), is a major driver of the revenue cycle and may affect other departmental metrics such as availability of records for care providers. Finally, costs must be closely monitored regardless if providers are using either an in-house or outsourced staffing model for document conversion services. The remainder of this article provides new metrics to assess, improve and monitor each of these areas of concern.

Measuring scan quality
All document conversion centers should imbed quality control points throughout the entire conversion process, and upon completion they should perform an agreed upon percentage of final quality assurance (QA). For QA, best practice is to review 5 to 10 percent of the total accounts received. QA should be performed by comparing each page of the entire paper record to the corresponding scanned image. Reports should be available that categorize the types of errors discovered. These reports will reveal the areas or staff processes that need remediation.

Workflow changes improve TAT
Turnaround time (TAT) is the easiest to measure, but improvement requires workflow changes. Such changes are not always easy to implement as they usually involve clinicians. Within HIM, it is less complicated but still requires measurement and reporting. Best practices should include a tracking system that monitors the chart from receipt of the record within the HIM department to the scanned images being released into the EHR system. Reports from the tracking system will identify sources that are slow to have discharged records delivered to HIM, not only the full chart but loose documentation, as well as components of the scanning process that are lacking in efficiency.

Comparing costs
Cost is the full cost per page to process, audit and release scanned documents to the EHR. For outsourced providers, this price is committed by contract and includes all staff and system costs. For healthcare organizations performing their own conversion, these costs reflect the actual cost of recruiting, retaining and managing scan capture staff, as well as the necessary imaging hardware, software, supplies and maintenance.

New methodologies to measure production
The document conversion process is clearly enhanced and operational efficiencies achieved by a continual process of data driven analysis of the above three categories. The cost and TAT metrics are fairly straightforward. The determination of the quality metric, while a bit more complicated, is also available and described here.

The new, empirical methodology to analyze document conversion quality is termed the Quality Performance Index (QPI). Several HIM departments are already using the QPI to measure the effectiveness of their internal operations or performance of an outsourced vendor. The methodology is available for use by all healthcare provider entities: hospitals, clinics or physician practices.

The Quality Performance Index (QPI)
The QPI is based on a formula that creates an index value based on the three factors mentioned above: quality, TAT, and cost. Specifically, the formula is:

QPI=((Quality Rate/Cost)/TAT)*100

Quality Rate – the percentage of actual errors as compared to total potential errors.

Cost – total cost of operations including staff, hardware, software, furniture, space, maintenance, supplies, etc.

TAT – the total time from receipt of the record within the document conversion center to its release into the EHR.

The resulting index values are typically double-digit numbers; where the higher the index values, the better the performance of the three factors in the formula. For example:

Quality Performance Index Results

Hospital Name

Turnaround Time (Hours)

Quality Performance Index

Hospital A



Hospital B



Hospital C



Hospital D



Quantitative analysis helps identify cost-reduction opportunities
HIM departments have been managing the document conversion process for decades. Measuring quality, TAT and cost of this process is often a challenge regardless if the process is outsourced or performed by in-house staff. It is only through effective assessment and monitoring that operational cost in this area can be reduced while quality is maintained.

By applying the QPI to the document conversion process, HIM directors can take a fresh look at outcomes, staffing and costs. In many cases, document conversion can be better accomplished by outsourced resources. Alternatively, where labor is abundant and technology is reliable, in-house staff may be the best option.

The document conversion process can be an important aspect of HIM’s contribution to easing financial pressures for the entire organization. A focused and carefully measured document conversion team can help streamline operations and reduce overall staffing costs in HIM.

Patrick Williamson is Vice President of Customer Operations, IOD Inc., Green Bay, Wisc. For more information, visit