Inside IT

Margret Amatayakul

Are you implementing an EHR and experiencing increased, rather than decreased, costs in the health information management (HIM) department at the same time? If so, don't be surprised-but also know that costs should eventually go down.

Conventional wisdom would suggest that as health records are automated, all of the following, and potentially even more, should occur:

  • Fewer paper charts should need to be pulled and filed because charts will be generated and maintained online.
  • No assembly of documents in the chart should be required because information will be accessible online.
  • Physicians should be alerted to chart deficiencies, thereby automatically eliminating the need for identifying and managing these manually.
  • The need for transcription should lessen as more structured data entry occurs.
  • There should be some reduction in manual requests for release of information where an organization supplies patients with electronic summaries of their records and/or a portal for them to access their records online.

Some healthcare IT experts have posited that coding should also be easier and faster, and that abstraction of data for quality reporting will be eliminated as a result of structured data entry that can lead to direct creation of reports or transactions that can be sent directly to a data collection warehouse.

Unfortunately, although some of the above reductions in HIM work are occurring as EHR systems are implemented, they are not occurring as quickly as some might expect. In addition, new tasks may be taking the place of older tasks, often with a higher skill level of employees needed.

The Impact of EHRs on Staffing

The exhibit below was created after observing a number of hospitals throughout their EHR implementation process. It illustrates the relative number of HIM staff needed as hospitals move from no automation of health records through various phases of EHR.

See Exhibit 


One task that has been added to HIM departments is document scanning using an electronic document management system (EDMS), sometimes combined with an enterprise master patient index (EMPI) implementation and/or clean-up project and, if not already in place, digital or speech dictation. All of these projects require HIM staff to be engaged in the selection and implementation process. Although hospitals use different means to account for the costs of these systems (especially the hardware necessary for EDMS), there is always some form of expense added to departmental budgets when these systems are implemented. Retraining of staff, replacement of staff, and an increase in staff for quality control add to personnel costs, with the result often being no difference or even an increase in costs in comparison with costs for pulling and filing charts. Finally, many large EDMS projects require a chart staging area to be built during the initial implementation, redesign of file room space, and, in many cases, additional costs for warehousing and/or destruction of records.

Digital dictation has generally been found to have no difference in transcription expense, while speech dictation should reduce transcription expense-but often does not if it is managed improperly. Not only does speech dictation require that transcriptionists work more closely with physicians to acclimate them with speech dictation, but also many transcriptionists continue to listen to the entire dictation file to make corrections, rather than read the output and fast forward through the dictation to listen and make corrections, where appropriate. (Note: It takes three times longer to speak-and therefore, to listen-than to read. The result is that there should be a reduction of transcriptionists by at least half with speech dictation, but this is often not the case.)

The next increases in staff relate to the addition of revenue cycle management components of coding and abstracting, release of information, and chart deficiency functions become part of the EHR. HIM departments often add IT specialists to their departments to help in the system design, training, and subsequent trouble shooting associated with adding these functions to the EHR system.

Also, there may be new functions added to the department at this time, such as the ability to maintain a provider index. Sometimes the abstracting function in the HIM department that typically has related only to claims data abstraction is expanded to abstract quality measurement data, such as for core-measure reporting. Although the addition of this function generally requires only a shift of existing staff from one department to another, adding such functions to the EHR contributes to a relative increase in HIM staff and costs. Until more clinicians directly use the EHR, such data cannot be automatically generated from the EHR. In the meantime, abstracting may actually take more time because the EHR does not retrospectively display the data in the same manner as paper charts. In addition, external auditors who come into the HIM department to abstract charts will require training on the EHR and, often, more ongoing support as the EHR evolves.

As nursing documentation goes live on the EHR system, another new function for HIM departments will emerge: error correction in the EHR. HIM departments are finding that they need to add at least one staff person, if not several, to manage corrections/amendments in EHRs. Because EHRs do not enable clinicians to "cross out" erroneous entries or margins where clinicians can add correct information, the process of making these corrections is tedious and complicated.

Many hospitals implement point-of-care documentation with nursing staff as one of their first EHR functions. These often include nursing flow sheets and medication administration records. During the early phases of EHR implementation, hospitals may ask clinicians to maintain diagnostic studies results online while recording everything else on paper. However, once nursing documentation goes online, most hospitals will want to avoid a hybrid record situation-part-paper, part-electronic maintenance of records, or maintenance that consists partly of scanned documents and partly of structured data. As a result, hospitals often print the nursing documentation, then scan it into the EDMS system. This practice not only adds work for the HIM department, but also results in a higher amount of printed output than would typically be generated via manual documentation.

Only when computerized provider order entry (CPOE) is implemented do HIM departments generally begin to experience significant reduction in staff. At this point, physicians will want greater access to other information online, and the CPOE may include clinical decision support that requires data from other structured data sources. This feature will lead to a reduction in the amount of paper printed for scanning. Ultimately, the only scanning that will be required is of documents from external sources. Chart deficiency processing also will become more of an online activity as CPOE is implemented. Although some hospitals are revising their deficiency policies to improve enforcement, such activity may produce more work for HIM departments.

Understanding the Hidden Costs of an EHR

About half of all HIM departments in hospitals report to a CFO. But it is frustrating to CFOs to see costs increase after an EHR implementation, rather than decrease. It's important for healthcare CFOs to work closely with their HIM departments as they make the transition to an EHR system. Doing so will help reduce the frustrations associated with EHR implementation.

Margret Amatayakul, RHIA, FHIMSS, is president, Margret\A Consulting, LLC, Schaumburg, Ill. (

Publication Date: Tuesday, June 01, 2010

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