What steps would you take as a consultant hired to assess the feasibility and functions for selection and implementation of an electronic document and record management system at a large multi-specialty clinic?
Enterprise Content and Record Management
Documents, records, and unstructured data of all types continue to proliferate, making it increasingly more difficult to locate and retrieve content. The evolving discipline of enterprise content management (ECM) is an integrative view that brings together concepts like data governance and data stewardship, practices such as document and record management, and work in such fields as thesaurus and ontology development to help tame the content chaos.
There are a number of practices and technologies that are used to manage content for the primary purposes of searching for, locating, and retrieving information. These systems can be viewed as a continuum from those that are simpler with less functionality, such as document imaging systems, to those that the more complex, such as electronic content management. At its simplest, document imaging is a system consisting of software and hardware that converts source documents to digital format. Systems that have mid-range functionality are electronic document management systems that automate the preparation, organization, tracking, and distribution of electronic documents. Systems and processes with high-end functionality are often referred to as content management systems. These more complex systems are able to move beyond categorization of documents and records to classifying content through the use of taxonomies, thesauri, and ontologies.
Content management is the entirety of practices and technologies used to manage the lifecycle of content from creation, capture, or receipt through archiving and destruction. The content management roadmap must be aligned with the strategic objectives of the organization, support business process and stakeholder needs, and be framed within a data governance perspective.
Chapter 9
Enterprise Content and Record Management
St. Rita’s EIM Team Questions
What is the nature of content, document, and record management?
What are the functions and technologies for content management?
Are there overlaps between content and metadata management?
What implementation and DG issues exist with content management?
Content and record management concepts
Content and Record Management Terminology
Information created, received, and maintained as evidence and information by an organization or person, in pursuance of legal obligations or in the transaction of business
As a business record, records must not be changed and must be maintained by the organization in an unalterable form
Content and Record Management Terminology
Record characteristics
Content: the data or information within the record that composes its intellectual substance
Structure: the format of the record and its relationship to the record’s content
Context: the circumstances about the record’s creation, receipt, and use (for example, how it was created, when it was created, and by whom it was created), and links to other records
Identifying What Documentation Constitutes a Record
Was it made, sent, or received in the course of business?
Does it document a decision?
Does it document advice given?
Does it document a process of arriving at a decision?
Is it required by legislation?
Content and Record Management Terminology
Recorded information or object which can be treated as a unit
Not considered to be associated with the criteria for a business transaction or a legal requirement
Can be updated and do not have to be maintainedby the organization for legal compliance
Can become records if they are used in a business transaction or created to document a transaction
Content and Record Management Terminology
The intellectual substance of a record or document
Consists of the data or information, including text, video, sound, and images contained in documents and records, that fulfill the intended purpose of the documents or records
Includes structured and unstructured data
Document, record and content management
Electronic Systems for Document and Record Management
Continuum of systems from simpler with less functionality to complex with greater functionality
Electronic document management system (EDMS)
Electronic record management system (ERMS)
Electronic content Management (ECM)
Electronic Systems for Document and Record Management Continuum
Electronic Document and Record Management Methodology
Content management tools
Electronic Content Management (ECM)
Organizing, categorizing, and structuring data or resources so that they can be stored, published, and reused in multiple ways
Associated with the management of unstructured data
Includes text, image, video, and audio documents and records
Evolutionary successor to EDMS and ERMS
Drivers include increased accessibility to content for business operations and compliance
Collaboration Content Management
Collaboration tools enable people to create, share, and use common content
Tools create virtual workplaces where people can create, share, and edit common document types
Examples includeSharePoint and Lotus Quickr
Tools also allow social collaboration
Creation ofblogs and wikis, discussion boards
Collaboration Content Management
Collaboration tools create enormous amounts of content
Knowledge associated with this content is lost to the organization if it is not managed
Some content may constitute business records necessary for meeting legal and compliance requirements
Safeguards for availability, access, integrity, security, privacy must be put into place
Digital Asset Management (DAM)
The practices for organizing digital files such as images, video, audio, graphics, web pages, and photographs
Requires a categorization method to catalog the digital assets
Enterprise, mid-market, and light-weight DAMs
Web Content Management
Establishing processes to control the content of a website
Cataloging and indexing web content
Creation and use of content templates
Tracking media check-out and check-in
Content management classifications
Content Management Classification
Classification of content makes it easier to locate
Classification alternatives
The science or technique of classifying objects to identify them and help search and retrieve them
Types of taxonomies
Flat taxonomy
Facet taxonomy
Hierarchical model
Flat Taxonomy
The simplest type of taxonomy
A controlled set of categories where each object in the set has the same weight
A list of states
Alphabetical listing of people belonging to a specific group
Facet Taxonomy
Multiple characteristics are assigned to one object
No inherent relationship among the characteristics
Attributes of a book
Hierarchical Taxonomy
A tiered order of concepts and their relationships
Presupposes inheritance qualities from the “parent class” to the “child subclass.”
The child subclass inherits the parent’s set of characteristics and becomes more specialized
Classification of plants and animals (figure 9.2)
Automatic Categorization
Automatic creation of taxonomies through analyzing documents
Creates taxonomies through conceptual analysis, using mathematical analysis and comparisons
Mathematically analyzes example documents to calculate concepts that are used to develop categories to categorize documents
Provides ability to link content among objects (documents)
Dictionary thesaurus
Listing of alternative terms for a word
Information management thesaurus
A controlled list of terms linked together by semantic, hierarchical (parent-child), associative (related), or equivalence (synonymous) relationships
Categorize concepts and then map associated words to the concept
Information Management Thesaurus
Maps words to each other indicating broader, narrower, associated, or equivalent terms that represent a concept
Usually indicates the preferred term for a concept
In searching, use of a broader term retrieves more general results; searching using a narrower term retrieves more specific results
In searching use of a related term provides similar results
An example of an information management thesaurus is Medical Subject Headings (MeSH)
MeSH Thesaurus Example
More complex relationships between terms than a thesaurus
Focus is on a particular domain or subject
Describes terms more richly than a thesaurus
Describes a term by specific attributes in a structured format, such as noting properties, features, characteristics, or parameters of the term
Describes relationships between classes or inter-term relationships
Useful in data exchange
In the naming, meaning, equivalency, and relationships between core business entities, such as patient, provider, and supplier, within organizations and across healthcare systems.
Constructs such as “same as” or “equivalent property” help establish common semantics when the same business entity is called a different name in different processes or by different organizations
Examples:SNOMED CT and LOINC
In content management, metadata are used to classify documents
Considered a faceted taxonomy
Doses not provide the richness of association among classes or objects like an ontology
Content life cycle management
Content Life Cycle Management
A set of activities and content identification methods that:
Defines documents and records
Ensures the assignment of proper ownership
Enables the appropriate use, security, retention, and disposition of content
Promotes efficient search, location, and retrieval strategies
Content Life Cycle Management
Content Life Cycle Management Activities
Identify stakeholder and business needs
What content should be created, captured, and maintained to support business and end user needs?
Identify the creation, receipt, and capture of content
Who creates, receives, or captures content, when do they create it, and by what means?
Content Life Cycle Management Activities
Identify the uses of content (business processes and functions)
How will content be used for business operations and to meet legal and compliance mandates?
Identify the users of content
Who are the users and the classifications of document and record they use?
Content Life Cycle Management Activities
Develop a description of what constitutes a document and a record
What are the criteria for determining what constitutes a document?
What are the policies and practices for handling these?
What are the criteria for determining under what circumstances a document may become a record?
Content Life Cycle Management Activities
Associated criteria include:
Identifying document and record ownership and stewardship
Assigning access rights to documents and records
Developing data and audit controls
Assigning security levels to documents and records
Developing retention, archival and disposal policies for documents and records
Content Life Cycle Management Activities
Identify organization documents and records
Select content management technologies with functionalities to meet business needs
Categorize documents and records
Apply taxonomies or ontologies
If taxonomies are not available, develop these to meet organization needs and in accordance with established standards for classification development
Content Life Cycle Management Activities
Develop policies and practices that ensure quality content
Develop policies, procedures, and standards to ensure the quality of content from inception through final disposition
Applying Data Governance to enterprise content and record management
Applying Data Governance
Develop a strategy and roadmap for ECM
Create policies and procedures for content management
Establish policies and procedures that meet business, legal and regulatory requirements
Apply taxonomies, thesauri, and ontologies for content identification, location, and retrieval
Applying Data Governance
Implement stewardship processes that ensure content capture, maintenance, quality, and security over the content lifespan
Institute standards and audit procedures for content management
Coordinate content management with other DG functions (metadata management)
St. rita’s eim team Conclusions and
next steps
St. Rita’s EIM Team Conclusions
ECM is essential to manage the growing amount of unstructured data
Policies, processes and criteria must be developed to identify and distinguish between documents and records
Electronic systems for the management of documents, records, and content must be chosen that meet organizational needs
St. Rita’s EIM Team Conclusions
Taxonomies and ontologies play a key role in identifying, searching, and retrieving information
Policies and processes must be in place to management the entire life cycle of content to meet business, regulatory, and legal needs
ECM will play a big role in the success of health information exchange
St. Rita’s EIM Team Next Steps
Develop a roadmap to help chart how SRHS can develop ECM
Investigate appropriate taxonomies and ontologies for document, record, and content management
Evaluate the next EIM domain, data security management
Kajal Patel
Information Governance
Assignment 5: Feasibility and Functions
What steps would you take as a consultant hired to assess the feasibility and functions for selection and implementation of an electronic document and record management system at a large multi-specialty clinic?
1. Build your Electronic Health Record (EHR) Implementation Team.
When one is implementing his/her EHR, one needs a strong team to help the process go as smoothly as possible. The team can include staff members such as physicians, nurses, medical assistants and administrative staff. Team members will assist the process by teaching colleagues EHR skills and serving as messengers to the implementation team to identify challenges along the way.
A lead superuser, lead physician, and project manager are three essential roles to consider while building your team, lead a super user. That is; the lead superuser is the resident in-house EHR expert. Whereby, a few duties may include template creation and developing workflows. This position may also be responsible for creating standard operating procedures to address problems users come across as they use the system.
2). Prepare the Software
That is, when implementing your EHR, you need to ensure that the security measures are met with an aim of not violating HIPPA. Your organization may need to conduct a HIPPA risk assessment where you can work with your health IT vendor to make sure the software is compliant.
3) Determine Your Hardware Needs
By maintaining this, your hardware choices will have a significant impact on the time and money your practice uses. For instance, having a printer in every room can save physicians up to 30 minutes a day. However, some practices provide each staff member with their own tablet or laptop to save time logging in and out between each patient interaction.
4) Consider The Patient Treatment Room
Since the EHR program requires an electronic data entry, the room layout can have a substantial impact on patient engagement and satisfaction. If the staff and physician face away from the patient while entering data, patients may feel like they are not being heard. And this is solved through various ways like triangle of trust.

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