Health Information Chapter 8

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Health Information Functions

What do HIM functions usually involve?

•HIM functions usually involve ensuring the quality, security, and availability of health information as it follows the patient through the health system.
•The HIM department also monitors the quality of patient information, ensuring that the information is maintained and protected in accordance with federal, state, and local regulations and the guidelines issued by various accrediting bodies

What are the HIM department's most important functions?

•Among the HIM department's most important functions is that of storage and retrieval of patient information
•Although computers are used widely in healthcare organizations today, many organizations still have an enormous volume of information documented on paper.

What will be used to store patient information as healthcare organizations transition to EHR?

•As healthcare organizations make the transition to an electronic health record (EHR), paper or hybrid record systems may still be used to store patient information

Regardless of the type of storage system used, how must patient information be stored?

Regardless of the type of storage system used, patient information must be stored in a manner that ensures its accessibility to authorized users whenever and wherever it is needed

In most healthcare organizations, the HIM department also manages several critical support services, what are these?

In addition to the storage and retrieval function, the HIM department also typically manages the following support services:

•Record processing
•Monitoring of record completion
•Transcription
•Release of patient information
•Clinical coding

The services managed by the HIM department vary depending on the organization. Besides the typical HIM functions, the HIM dept may manage what functions?

Besides the typical HIM functions, the HIM department may manage the following functions:
•Research and statistics
•Cancer and/or trauma registries
•Birth certificate completion

What kind of relationship exists between the HIM department and many other departments within a healthcare organization?

An interdepartmental relationship exists between the HIM department and many other departments within a healthcare organization.

HIM functions support what kinds of functions?

HIM functions support patient care, billing, and patient registration.

The functions associated with patient care, billing, and patient registration also affect what?

The processes managed by the HIM department.

The HIM department works closely with which department to support the electronic health record environment?

The information systems department and HIM work together to support the electronic health record environment.

Theory into Practice: This case study presents a healthcare facility's journey toward implementation of an electronic health record.

It demonstrates the complexity of the process and similarities that exist between paper-based, hybrid, and electronic health records.

Background of case study:

•Central Community Medical Center (CCMC) is a 600-bed urban hospital located in the downtown of a major metropolitan area.
•The medical center is one of five hospitals belonging to the Midwest Healthcare systems.
•The medical center is a full-service teaching hospital with services ranging from medical, surgical, obstetrics, pediatrics, wound care, trauma care, and heart care, to outpatient clinics and services.
•CCMC has an average of 15,000 inpatient discharges each year and approximately 90,000 outpatient visits per year.
•Up until two years ago, Central Community Medical Center's HIM department operated as a traditional paper-based health records department.

An administrative decision was made to implement an electronic health record, and CCMC is the 2nd hospital w/in the midwest healthcare system to implement the EHR; therefore:

•The vendor selection was already established.
•The Healthcare system decided that all hospitals would use the same vendor to facilitate the interoperability and consistency of the EHR between facilities.

The Planning Process: The first step to planning for the various components of implementing an EHR:

•Establish a steering committee
•Key players needed to be identified and included in the planning process
•The steering committee consisted of a project manager and approximately 20 individuals from the health information management team and information systems team.

Besides the project mgr, and approx 20 people from the HIM and information systems teams, who else was part of the steering committee?

•Appropriate representatives from administration, medical staff, nursing, and other ancillary departments were included on the steering committee, along with vendor representatives.

What was the steering committee charged with? What was then developed?

•The steering committee was charged with determining how the vendor product would be implemented at the CCMC facility.
•Workgroups were developed
•The HIM workgroup activities are discussed in this case study.

Forms Redesign and Documentation Analysis: What was one of the main tasks completed by the HIM workgroup?

The HIM workgroup completed the task of identifying all forms utilized in the health record, as well as other sources of documentation that comprised the health record.

How long did the HIM workgroup task of identifying all forms utilized in the health record take, and what work was included?

This process took approximately one year to complete and included the creation of a forms catalog, development of a documentation matrix, forms redesign/standardization, and barcode application.

The forms catalog included what?

•The forms catalog included a copy of every form used by the healthcare facility to document patient care in the paper-based record.
•Duplicate forms or forms with similar data were reviewed to determine if a common form could be used across departments.

What was the next step after the first critical HIM workgroup step?

•The next step was to develop a documentation matrix.
•The forms included in the forms catalog, as well as, other sources of health record documentation were included in the matrix.
•For example, health record documentation generated and printed from the computer for inclusion in the health record (for example, printed laboratory results) was also identified and included in the documentation matrix.

What information was included in the documentation matrix?

•Name of form or documentation (for example, history and physical, progress notes, physician orders, graphic nursing forms, laboratory results, medication administration form, and so forth)
•Source of the documentation (for example, internal, external)
•Documenter of the information (for example, nursing, physician, physical therapist, radiology, surgical department, laboratory, and so forth)
•Data capture methodology (for example, paper form, printed results, voice recognition, transcription, electronic forms, and so forth)
•Health record location (for example, physician section, nursing section, laboratory section, radiology section, and so forth)
•Name of computer systems used to provide electronic documentation

How then was the documentation matrix used in this case study?

The documentation matrix was then used to determine what documentation would be scanned and imaged in the electronic document management system (EDMS), what documentation would be electronically transmitted into the EDMS, and what departments or individuals would need to assist with the integration of health record documentation into the EDMS.

Once each form was identified, what was applied to paper forms scanned into the EDMS? Why is this needed?

•Once each form was identified, a barcode was applied to paper forms that would be scanned into the EDMS
•The barcode on the forms was needed so forms could be automatically indexed and routed to the correct location within the EDMS. Indexing rules were applied to scanned images and electronically fed documentation
•The rules allowed the documentation to be auto-indexed to the correct location within the EDMS. Another task in form redesign was to standardize the location of the barcode on paper forms to be scanned.

What does the information systems workgroup use the documentation matrix to assist with?

The information systems (IS) workgroup used the documentation matrix to assist with the identification of computer interfaces that needed to be in place in order for electronic transmission of the documentation to work properly.

Why was the workflow analysis also performed on the paper-based HIM procedures?

Workflow analysis was also performed on the paper-based HIM procedures to see what processes in the current workflow could be eliminated and what new processes would need to be implemented with the adoption of the electronic health record components.

Workflow analysis: How was the current workflow demonstrated?

•The current workflow was graphically demonstrated in a process flow chart. •Several work processes that existed in the paper-based environment were replaced or revised in transitioning to a high-functioning hybrid record

Why were new productivity standards established?

New productivity standards were established to reflect the work processes of the hybrid record

Work queues were established in the EDMS to do what?

Work queues were established in the EDMS to mirror the many processes and uses of the electronic health record.

A sample of work queues established to accomplish the electronic work processes were: Internal HIM work queues:

•Record deficiency analysis queues
•Quality review
•Indexing
•"Loose sheets" queues
•Birth certificate queues
•Release of information queues
•Physician decline queues
•Medical coding queues

A sample of work queues established to accomplish the electronic work processes were: Physician work queues:

•Records needing dictation
•Records needing signature
•Records requiring text editing
•Medical coding queries
—Outpatient surgeries
—Inpatient
—Emergency department records
—Ancillary coding

A sample of work queues established to accomplish the electronic work processes were: Management work queues:

Medical coding questions

A sample of work queues established to accomplish the electronic work processes were: Supervisor monitoring:

Questions
Productivity
Quality review

A sample of work queues established to accomplish the electronic work processes were: Review work queues:

Quality outcome review
Cancer chart reviews
External review (temporary queues)
—Medicare
—Other payers
—Auditor review
—Accreditation review
—Department of health reviews

What was determined trough the documentation matrix and workflow analysis? What was determined about fetal monitoring?

•It was determined that 60 percent of the health record could be captured in the EDMS through electronic transmission of data and 40 percent of the health record would require the paper record be prepped and scanned as images into the EDMS
•It was determined that fetal monitoring strips would be maintained on paper because of the inability to capture the monitoring information electronically and the time required to scan the continuous feed of monitoring strip paper after discharge

What was formally defined at the completion of the documentation matrix?

After the documentation matrix and workflow analysis were completed, the healthcare facility formally defined the "legal health record" in a formal policy.

Prior to implementation, how was the EDMS tested? What did this assure?

Prior to implementation, the EDMS was tested in a test environment to assure that scanned images and electronically transmitted documentation were routed correctly.

How was the focus shifted as the facility approached the implementation date?

•As the facility approached the implementation date, focus shifted to training
•Key clinical staff were trained in the "train-the-trainer" style
•Online training modules were available for staff unable to attend "live" training sessions
•Most of the physician training was accomplished on an individual basis

Implementation: Change Management; What was the significant culture change for the health care facility?

•The implementation of a high-functioning hybrid record and
•The planned evolution of the paper health record to an electronic health record was a significant culture change for the health facility

Central Community Medical Center included change management in the planning process; bc of the significant change in work processes, what was needed?

Because of the significant change in work processes, HIM employees needed to be retrained for the new processes of prepping/scanning, indexing, quality review, and electronic chart analysis.

What did employees fear from the EHR implementation? What was used to help manage fears?

•Some employees feared that with the automation of the health record there might be job loss
•The employee assistance program was utilized to help manage the fears associated with the change

How was the staff reduction handled?

•Although the new processes did allow the facility to eliminate 2.0 FTE, the reduction of staff was handled through the process of not replacing employees who resigned from their jobs during the 18-month planning and implementation period.

What was the ultimate goal for the Central Community Medical center in transitioning to the hybrid?

Central Community Medical Center transitioned to the high-functioning hybrid record with the ultimate goal being to evolve to an electronic health record with minimal paper

How much of the health record is being scanned for inclusion into the EDMS? What is the long-term plan?

With 40 percent of the health record being scanned and imaged for inclusion into the EDMS, the long-term plan is to eliminate as much as possible of the scanned paper portions of the health record and increase the amount of documentation electronically transmitted.

As computer systems that are not interfaced with the EDMS are replaced or updated:

The IS department will work with vendors to assure the inclusion of the data in the EDMS via electronic transmission

In the future, what will there be more emphasis placed on? What will be the focus of future enhancements?

•In the future, there will be more emphasis on point-of-care documentation being entered directly into the computer via the use of databases or automated online forms
•Improvements to interoperability will be the focus of future enhancements of the electronic health record, which will support the health information exchange initiatives of the healthcare system and regional and national initiatives.

HIM Functions are __________ centered

information

What does it mean to say that HIM functions are information centered?

This means that they typically involve ensuring information quality, security, and availability

The medium in which the information is stored may dictate what?

How the specific functions are carried out. For example, storage of information in paper-based records involves different types of tasks than storage of information in electronic records.

Figure 8.1 provides a description of a fictional HIM department with paper-based, hybrid, and electronic records.

•The description includes many of the HIM functions discussed in this chapter
•It is important to note that these are typical functions
•Not all HIM departments are identical in organization or in the functions they perform
•Table 8.1 summarizes the some of the typical functions of the HIM department for paper-based and hybrid records and EHRs.

Figure 8.1. HIM functions at Community Hospital Medical Center

The HIM dept is responsible for all health records for the entire facility including both inpatient and outpatient records.
The medical training aspect of the facility adds another complicated dimension to the management of the health records

Functions performed within the HIM department include:

•Record processing (concurrent and retrospective analysis and monitoring of health record content)
•Record completion
•Storage and retrieval of health records (including monitoring and tracking of health record location)
•Release of patient information
•Clinical coding of diagnosis and procedures
•Transcription of medical reports (excluding pathology and radiology)
•Statistical and internal report generation
•Cancer and trauma registry

Function/Service: Storage and retrieval Paper-based system

•Patient care information documented on paper and housed in file folders.
•Records retrieved for patient care purposes, quality improvement studies, audits, and other authorized uses
•Records are delivered to the nursing units, outpatient surgery, and the emergency room as the patient is admitted or being treated

Function/Service: Storage and retrieval Hybrid system

•Patient care information documented both on paper and in the computer.
•Record is accessible to patient care areas via the computer by use of an electronic document management system (EDMS)
•If hospital is transitioning to the EHR, portions of the health record may be printed for use on the patient care unit

Function/Service: Storage and retrieval EHR system

Same electronic components utilized in the hybrid record, but the record resides entirely in electronic format with work processes performed via the computer

Record processing/completion: Paper-based

•After the patient is discharged from the hospital, the record is retrieved from the nursing unit. The record is then assembled or put in an order prescribed by the facility's policy and procedure manual. For example, the face sheet is usually the first page in the paper record
•The postdischarge order is usually different than the order of the record on the nursing unit
•After the record is assembled, it is analyzed for deficiencies, such as missing reports and signatures.
•Physicians visit the HIM department to complete deficiencies in records.
•The record is reanalyzed after completion to assure completeness of the process. Deficiencies are cleared from the computer

Record processing/completion: Hybrid system

•Portions of the record can be directly inputted into the EHR through computer interfaces (for example, transcribed reports, laboratory reports, emergency records, etc.) After the patient is discharged from the hospital, the paper record is prepared for imaging (scanning)
•Physicians complete the record from a computer that may be located remotely from the hospital.
•If electronic signatures, computer key, and electronic completion rules are applied, the deficiency system is updated once the physician completes his/her record
•Records are analyzed for deficiencies either manually by the HIM staff and/or by rules built into the computer system

Record processing/completion: EHR system

Entire health record available via the computer for completion. Work queues in the computer are used to route health records to appropriate person or area for completion

Transcription: Paper-based system

•May be completed in-house or outsourced to an outside service
•Physician dictates reports into a dictation system that records the voice. The transcriptionist types (transcribes) what the physician has dictated.
•The transcribed report is placed in the chart
•Reports commonly transcribed include: operative reports, history and physicals, discharge summaries, radiology reports, pathology reports, and consultations

Transcription: Hybrid and EHR system

•The process is basically the same as in the paper-based system, except that the transcribed reports are electronically added to the health record that resides within the computer
•Speech recognition technology may be applied to the front-end and back-end of the transcription process to facilitate the process

Release of information (ROI) Paper-based system:

•Reviews requests for health records for validity to assure compliance with federal and state regulations.
•Logs and verifies validity of requests for patient information.
•May copy the record in response to valid requests or may provide record for an outsourced copy service to process.
•May go to court in response to a subpoena or court order.
•Must have in-depth knowledge of laws and regulations governing the release of information

Release of information (ROI) Hybrid and EHR system:

•ROI process is basically the same as in the paper-based environment.
•As the EHR evolves there may be opportunities for the HIM professional's role to be expanded

Clinical coding Paper-based system:

•A code number(s) is/are assigned to the diagnoses and procedures documented in the health record. The coder looks the code number up in a coding book or by entering key words into the computer using software called an encoder
•ICD-9-CM and CPT are the two primary coding systems used in a hospital setting. ICD-10-CM and ICD-10-PCS will replace ICD-9-CM
•Other information is abstracted from the record for reporting and reimbursement purposes
•Coding takes place on-site within the HIM department

Clinical coding Hybrid and EHR system:

•The process is the same as the paper-based system, except that in the EHR environment, the record that is reviewed is the electronic health record
•Coding may be remote to hospital; home-based coding is possible
•As the structure of the EHR evolves, computer-assisted coding may be utilized
•Data abstracting may be reduced or eliminated as automatic data capture is implemented

What might be considered the most fundamental responsibilities of most HIM departments?

•The functions (storage and retrieval, record processing, record completion, transcription, release of information [ROI], clinical coding)

As mentioned earlier, in some institutions, HIM duties also include what functions that may not fall within the traditonal range of HIM department responsibilities?

•Clinical quality performance activities
•Research and statistics
•Maintenance of cancer and other registries
•Support for medical staff committee functions
•Responsibility for birth certificate submission to state departments of public health
•Even though these functions may not fall within the traditional range of HIM department responsibilities, health information technicians (HITs) sometimes do perform them

Master Patient Index (MPI)

•Probably the most important index used by the HIM department is the master patient index (MPI)
•The MPI functions as the primary guide to locating pertinent demographic data about the patient and his or her health record number
•Without the information contained in the MPI, it would be almost impossible to locate a patient's health record in most organizations that use a numeric filing system
•The MPI is the permanent record of every patient ever seen in the healthcare entity

The amount of information contained on each patient in the MPI varies from facility to facility. However, the basic information usually includes:

•Patient's last, first, and middle names
•Patient's health record number(s)
•Patient's date of birth
•Patient's gender
•Dates of encounter (admission and discharge dates are usually maintained for inpatients)
•Additional information such as address, telephone number, and attending physician for each encounter also may be recorded in the index
•Figure 8.2 provides an example of an input screen for an electronic MPI system

Storage and retrieval:

A healthcare facility's method for safely and securely maintaining and archiving individual patient health records for future reference

Record processing:

The processes that encompass the creation, maintenance, and updating of each patient's medical record

Record completion:

The process whereby healthcare professionals are able to access, complete, and/or authenticate a specific patient's medical information

Transcription:

The process of deciphering and typing medical dictation

Release of information (ROI):

The process of disclosing patient-identifiable information from the health record to another party

Clinical coding:

The process of assigning numeric or alphanumeric classifications to diagnostic and procedural statements

Today, instead of a manually maintained index, it is common practice to have:

An electronic MPI

The patient registration system is also known as:

The registration, admission, discharge, transfer (R-ADT) system, functions as the MPI

Often the patient registration system functions as what?

The MPI

The benefits of an electronic system include:

•The ability to access data by more than one individual at a time
•In addition, edit checks can be applied against specific fields in the database to better ensure data accuracy
•An electronic index also can be easily cross-referenced—for example, when a patient has used more than one name during hospital or clinic visits

An electronic MPI permits the use of several search techniques for locating an existing patient's information. For example, common techniques include:

•Alphabetical or phonetic searches and •Searches by specific data elements such as medical record or billing number, date of birth, or Social Security number

Once the patient's medical record number is identified using the MPI, the health record can be:

Located which facilitates the coordination of care by caregivers and provides the physician and others access to the patient's history of previous encounters

Small facilities may still use a manual MPI. What is a manual MPI?

•In a manual MPI, index cards (usually 3 by 5 inches) are used to record patient information in typewritten format
•MPI cards are usually filed in strict alphabetical order in rotary files or vertical carousel storage files described previously

Maintenance of Master Patient Index, what is essential to ensure the integrity of the MPI?

To ensure the integrity of the MPI, several quality control mechanisms are essential

The following section describes some of the quality issues and examines how these can be controlled. Quality Issues in MPI Systems:

•Both manual and computerized MPIs are prone to errors, which adversely affects the integrity of the health record system

•Manual MPI indexes pose several problems:

•One major concern is misfiled cards
•A misfiled MPI card makes it almost impossible to locate a patient's health record
•At the very least, record retrieval time is increased significantly
•This is why monitoring systems must be in place to ensure correct alphabetical filing of every card
•Many HIM departments have established a process whereby another employee rechecks every filed MPI card for proper alphabetical location
•For example, all MPI cards filed on the day shift are tagged and an employee from the evening shift rechecks the accuracy of each card's location.

Another manual system disadvantage is that:

•Usually only one person at a time can access the index
•This definitely slows down retrieval time. •Furthermore, updating, cross-referencing, and maintaining a manual system is more time-consuming than an automated system.

Both manual and electronic MPI systems can contain erroneous data that:

•Make patient and health record identification difficult
•These errors may include misspellings, incorrect demographic data, transposition of numbers, and typographical errors to name a few
•When the data integrity of the MPI has been compromised in this way the faulty data are dispersed throughout the organization risking treatment errors and billing problems, and distorting data analysis of the organization's patient population (Dimick 2009)

Frequently an incomplete or rushed search of an electronic MPI at the time of registration can cause what?

•Creation of a duplicate record number for an individual or match an individual with the wrong health record number
•Duplicate, overlay, and overlap medical record number issues, discussed below, are significant problems
•To help mitigate these, some facilities have instituted registration improvement programs, which can feature cross-department committees whose purpose is to reduce registration errors and clean up the MPI (Dimick 2009).

Duplicate, Overlay, and Overlap Medical Record Number Issues: When do the most common MPI errors occur?

Whether the system is electronic or manual, the most common MPI errors occur at the point of registration when existing MPI information is not located.

What is the MPI the key to?

The MPI is the key to locating specific patient information.

What problems can arise if patient information is not located?

•For example, as stated earlier, these may include billing errors
•Performance of unnecessary duplicate tests
•Increased legal exposure in the area of adverse treatment outcomes

Failure to correctly identify an individual in an MPI may result in one or more integrity problems, and in potential patient care, billing, legal or other problems:

•The first case is the assignment of a new patient medical record number to an individual that has an existing medical record number
•This is called a duplicate medical record number and results in the creation of a new medical record.

Duplicate medical record numbers and their associated records results in what? What is a duplicate medical record number?

•A patient having duplicate medical record numbers with medical information in disparate medical records (Altendorf 2007)
•The situation in which a patient that already has a medical record number is assigned a new number.

Another situation arising from the failure to correctly identify an individual in an MPI is called an overlay, what is this and what are its consequences?

•An overlay is where a patient is assigned another patient's medical record number; situation in which a patient is issued a medical record number that has been previously issued to a different patient
•The consequence of this situation is that medical information from two or more individuals is comingled or combined, resulting in problems identifying what medical information belongs to which patient

The third case is called an overlap, what is this and when does it occur?

•An overlap is when more than one medical record number exists for the same patient within an enterprise at different facilities or in different databases
•Overlaps may occur in organizations that have multiple facilities, such as a multi-hospital system, or can occur in health information exchanges
•Frequently this problem arises when there are facility or organization mergers and an enterprise master person/patient index (EMPI) is created

Strategies for MPI Integrity: With more and more consolidations and mergers in healthcare, what is becoming increasingly difficult? Why must MPI integrity be maintained?

•With more and more consolidations and mergers occurring among healthcare organizations and the establishment of health information exchanges, tracking patient information is increasingly more difficult
•MPI integrity, however, must be maintained in order to avoid patient safety, customer service, and risk management, legal, and other issues.

What are most integrity issues caused by? What are some examples of these errors?

•Most integrity issues are caused by human error
•Some of these may be input errors by personnel such as misspellings, typographical errors, and transposition of numbers among others
•Others may be retrieval errors such as using poor search strategies or reading errors
•And still others may be due to inaccurate information being provided by the patient or client

Initially, the MPI "clean-up" process is required to do what? How is this done, and by whom?

•Initially, the MPI "clean-up" process is required to fix duplicates, overlay, and overlap errors within the MPI
•This is generally done by a vendor who uses a sophisticated probabilistic algorithm that is based on complex mathematical principles to identify and fix these problems (Altendorf 2007)
•However, prevention of the problems should be the front line of defense

What are the first steps for prevention of integrity issues?

Among the first steps for prevention is to establish an education awareness program that makes organization employees who work with the MPI aware of its importance to patient care and organizational operations.

Awareness education

•Awareness education should be coupled with employee training for individuals who are working with the MPI
•There should also be standards in place for capturing and recording patient demographic data
•Quality improvement techniques should be implemented, such as benchmarking and performance standards (see chapter 11) and linked to employee productivity reports to hold staff accountable for accuracy (AHIMA MPI Task Force 2004)
•Policies and procedures such as those that identify MPI core data elements and their associated data definitions should also be established

Continual monitoring of MPI data quality is important and the responsibility for MPI maintenance should be under the direction of HIM professionals. A comprehensive MPI maintenance program should include (AHIMA MPI Task Force 2004):

•Ongoing process to identify and address existing errors
•Advanced person search capabilities for minimizing the creation of new errors
•Mechanism for efficiently detecting, reviewing, and resolving potential errors
•Ability to reliably link different medical record numbers and other identifiers for the same person to create an enterprise view of the person
•Consideration of the types of physical merges (files, film, and so forth) and the interfaces and correction routines to other electronic systems that are populated or updated by the EMPI

Patient Identity in a Health Information Exchange Environment, what is health information exchange (HIE) used to describe?

•As stated in chapter 4, health information exchange (HIE) is frequently used to describe both the sharing of health information electronically among two or more entities and also an organization that provides services to accomplish this information exchange

What do the HIE networks cover?

•These networks usually cover local or state geographical regions and are the building blocks of the proposed national health information network (NHIN)

What is the purpose of HIE?

•The purpose of an HIE is to increase the availability of health information to authorized stakeholders in order to improve quality and safety of healthcare delivery

What is paramount to ensure integrity of patient identity in health information exchange?

To ensure integrity of patient identity in health information exchange, standardization of health information exchange practices is paramount

What must the focus on technical exchange of data between systems ensure?

•The focus on technical exchange of data between systems must ensure the quality of the data exchanged (that is, data validity and integrity, and quality of key data values)

•A quality health information exchange environment begins with what?

•Accurate patient identification
•However, mechanisms must be in place to achieve this goal

The challenge of accurately capturing a patient's key demographic data in a single organization and preventing duplicate medical records is difficult; but this challenge becomes even more complicated when doing what?

•This challenge becomes even more complicated when attempting to link patient information among a group of different organizations

There are several competing identification methods that can be used to link patient information among a group of different organizations?

•There are several competing identification methods that can be used
•One common method is probabilistic matching that attempts to match an individual on multiple data elements such as name, date of birth, address, gender, and other items
•Probabilistic matching has been used in healthcare and other industries for decades

Many HIE organizations have formed multidisciplinary data governance steering committees to address what?

•How patient identification will be handled in the HIE
•These committees determine, for example, what data are used in the matching algorithm, how many potential candidate matches will be presented to the user, and data quality standards

Health information professionals are taking the lead in ensuring integrity:

•Of personal identification in HIEs
•They are frequently members of data governance steering committees helping to define how patient identification is performed as well as addressing data security and privacy issues

Identification Systems: The health record number (also called the medical record number) is a key data element in the what?

•The health record number (also called the medical record number) is a key data element in the MPI
•It is used as a unique personal identifier and is also used in paper-based numerical filing systems to locate records and in electronic systems to link records

Although it is typically assigned at the point of patient registration, the HIM department is usually responsible for:

•The integrity of health record number assignment and for ensuring that no two patients receive the same number
•The HIM department also ensures that the identification numbering system is such that all of an individual patient's records are stored together or can be linked together

Why is the health record number important?

•The health record number is important because it uniquely identifies not only the patient, but also the patient's record
•Patient care documentation generated as part of the patient's episode of care is identified and physically filed or linked in an electronic system

Examples of documentation and medical reports found in health records are?

•The history and physical, the discharge summary, operative notes, pathology reports, laboratory reports, radiology reports, and nursing notes
•Thus, having a numbering system is important for efficiently storing and retrieving information about a single patient.

It is generally agreed that Social Security numbers (SSNs) should not be used as patient identifiers.

•The Social Security Administration is adamant in its opposition to using the SSN for purposes other than those identified by law
•The American Health Information Management Association (AHIMA) is in agreement on this issue due to privacy, confidentiality, and security issues related to the use of the SSN

The type of health record numbering system used varies from facility to facility.

•Four types of systems used most commonly in association with paper-based record systems are discussed below as is the identification system most frequently used with EHRs
•The system used determines the procedure for assigning the health record number and the method for filing the patient record in a paper-based system

Identification Systems for Paper-based Health Records: What is the Serial numbering system?

In the serial numbering system, a patient receives a unique numerical identifier for each encounter or admission to a healthcare facility.

Why is the numbering system called serial?

•The numbering system is called serial because numbers are issued in a series
•For example, Mr. Jones is admitted to the hospital at 8:00 a.m. on October 12 and given number 786544. Mrs. Wright, who registered at 8:15 a.m. on the same day, receives the next available number, 78654
•Thus, in a serial numbering system each patient receives the next available number in the series

With this serial numbering system, a patient admitted to a healthcare facility on three different occasions would receive how many health record numbers? What is one disadvantage?

•With this system, a patient admitted to a healthcare facility on three different occasions receives three different health record numbers
•The information compiled for each admission is filed with the health record for each encounter
•One disadvantage to the serial numbering system is that information about the patient's care and treatment is filed in separate health records and at separate locations
•This makes retrieval of all patient information less efficient and storage more costly

In addition to retrieval inefficiencies and the costs associated with file folders, what is another drawback to this numbering system?

•This numbering system is time-consuming in terms of documentation
•Each time a patient returns to the healthcare facility, manual index cards or computer systems must be updated to reflect the addition of a new serial number and each update presents an opportunity for input error

Unit Numbering System: where is it most commonly used? What can this system address?

•The unit numbering system is most commonly used in large healthcare facilities
•Many of the disadvantages to the serial numbering system can be addressed by using a unit number
•In the unit numbering system, the patient receives a unique health record number at the time of the first encounter
•For all subsequent encounters for a particular patient, the health record number that was assigned for the first encounter is used

What is one advantage to the unit numbering system? What does it improve?

•One advantage to this method is that all information, regardless of the number of encounters, can be filed or linked together
•Having all the information related to the patient filed in one location facilitates communication among caregivers and improves operational efficiency

What must be available for the unit numbering system to work effectively?

•For the unit numbering system to work effectively, patient demographic and health record number information must be available to all areas of the facility that process patient registrations
•For example, clerks in the admitting, emergency, and clinical departments must have access to a database of previous patients and their health record numbers
•Access to such information is not a problem for organizations that make the information available to the registration areas via a computer network and electronic MPI
•However, use of a manual system or an incomplete search of a computerized system increases the likelihood that duplicate numbers may be assigned to a patient
•Therefore, the unit numbering system generally works best in a computerized environment

Serial-unit numbering system

A health record identification system in which patient numbers are assigned in a serial manner but records are brought forward and filed under the last number assigned

The serial-unit numbering system is an attempt to:

•The serial-unit numbering system is an attempt to combine the strengths and minimize the weaknesses of the serial and unit numbering systems

How does the serial-unit numbering system work? What does it create?

•In this system, numbers are assigned in a serial manner, just as they are in the serial numbering system
•However, during each new patient encounter, the previous health records are brought forward and filed under the last assigned health record number
•This creates a unit record

What does the serial-unit numbering system help to alleviate? What else does it help address?

•The serial-unit numbering system helps alleviate the problem of access to previous patient demographic and health record number information
•It also helps in addressing problems associated with retrieval and the cost of the serial system.

What kind of organizations use the alphabetic identification and Filing System? How does it work?

•Some small facilities and clinics use an alphabetic patient identification and filing system
•In this system, the patient's last name is used as the first source of identification and his or her first name and middle initial provide further identification.

What is the disadvantage to the alphabetic Identification and Filing System?

•The disadvantage to this system is that a given community may have several persons with the same or a similar name •In this case, the facility routinely uses date of birth as the next step in the process of identifying a patient

What are some conveniences to alphabetic identification and filing system?

•There are some conveniences to alphabetic identification and filing
•It is simple to locate a health record without first accessing an assigned number
•However, each entry must be double-checked to verify that the correct patient record is being used

Identification Systems Used for Electronic Health Records: what numbering method is most commonly used as the unique identifier in the EHR environment?

•Unit numbering is the method most commonly used as the unique identifier in the EHR environment

For search and retrieval purposes, what can be used to locate patient records in EHRs?

•For search and retrieval purposes, identifiers other than the health record number can be used to locate patient records in EHRs
•The patient account number and patient name are often used to find a patient's health record stored electronically within a computer system

Because correcting a digital record can be complex, it is very important to do what?

It is very important to verify that the correct record has been accessed by checking the full name, date of birth, and other factors before making entries or using information for care.

The process for checking patient records should be included:

in the facility's charting policies and procedures.

8.1 Check your understanding:
1. The system in which a health record number is assigned at the first encounter and then used for all subsequent healthcare encounters is the:

B. Unit numbering system

2. The primary guide to locating a record in a numerical filing system is the:

A. Master patient index

3. All forms should:

A. Contain a unique identifier

4. The health record number is typically assigned by:

A. Patient registration

5. Which of the following is used to locate an electronic health record?

A. Health record number

6. John Smith, treated as a patient at a multi-hospital system, has three medical record numbers. The term used to describe multiple health record numbers is:

A. Duplicates

7. Which of the following should be part of a comprehensive MPI maintenance program?

A. Advanced person search

8. Which of the following is true about the Social Security number?

C. Both AHIMA and the Social Security Administration oppose using the Social Security number as the health record identifier

9. The most common numbering system used in healthcare is:

B. Unit numbering

10. Which identification system is at a disadvantage when there are two patients with the same name?

D. Alphabetic

HIM Functions in a Paper-based Environment:

•There are still many organizations that rely on paper-based documentation methods to varying degrees
•Some organizations remain completely paper-based, while others use a combination of paper-based and electronic formats.

HIT professional must be familiar with:

•Best practices for all health record environments
•The following section describes processes for the creation, storage, and maintenance of paper-based records

Health record number:

A unique numeric or alphanumeric identifier assigned to each patient's record upon admission to a healthcare facility

Record Storage and Retrieval Functions: What is one of the HIM dept's most important functions?

•The storage and retrieval of patient information is one of the HIM department's most important functions •The department must ensure that health records are stored safely and that mechanisms are in place to efficiently retrieve them for patient care or other purposes.
•Moreover, the data contained in patient health records are confidential; thus, mechanisms must be in place to ensure that only authorized individuals have access to them

What has traditionally been the most common archival medium across healthcare delivery sites? How are records contained in a paper-based storage system?

•Storage of paper-based health records has traditionally been the most common archival medium
•In paper-based storage systems, each health record is contained in a special file folder that is filed either alphabetically or numerically, depending on the size of the organization

How do small orgs like a dr.'s office file its health records? How are they stored in larger facilities?

•A small organization such as a physician's office practice may file its health records alphabetically in open-shelf files
•Clinics, hospitals, long-term care facilities, and other larger facilities file their records numerically, using the patient's health record number as the primary identifier.

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