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:
•Monitoring of record completion
•Release of patient information
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
•"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
—Emergency department records
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:
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)
—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.
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)
•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
•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
The processes that encompass the creation, maintenance, and updating of each patient's medical record
The process whereby healthcare professionals are able to access, complete, and/or authenticate a specific patient's medical information
Release of information (ROI):
The process of disclosing patient-identifiable information from the health record to another party
The process of assigning numeric or alphanumeric classifications to diagnostic and procedural statements
The patient registration system is also known as:
The registration, admission, discharge, transfer (R-ADT) system, functions as 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 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 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
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:
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
10. Which identification system is at a disadvantage when there are two patients with the same name?
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.
In-house archival of paper-based health records is not the healthcare organization's only storage option, what are other options?
•Health records also may be stored off-site, microfilmed, or scanned as digital images. Indeed, large HIM departments may have all these storage mechanisms in place
•Many large healthcare organizations are transitioning toward or have implemented electronically stored health records
Facilities transitioning to the EHR sometimes use what kind of records? Define this kind of record.
•Facilities transitioning to the EHR sometimes use a hybrid record
•A hybrid record is a combination of paper-based and electronically stored health data
•The hybrid record environment includes a combination of paper-based and EHR systems
What would happen without a good storage and retrieval filing system?
Without a good storage and retrieval filing system, it would be impossible to locate and retrieve health records when they are needed
The following subsections discuss key elements of the storage and retrieval function:
•Identification systems for paper-based health records and EHRs
•Filing systems for paper-based health records
•Retrieval and tracking systems
Filing Systems for Paper-based Health Records:
The filing system used by a healthcare facility maintaining paper-based health records refers to the procedure in which the file folders are placed on shelving units or in filing cabinets.
The unique health record number assigned to a patient upon admission to a healthcare facility is also the number that is used for:
•The unique health record number assigned to a patient upon admission to a healthcare facility is the number also used to file the record in a numeric filing system
•Likewise, the patient's name is used as the basis for filing in an alphabetical filing system
Why must the HIM department carefully consider the types of filing and storage systems thy use?
•Records that cannot be located and retrieved when needed serve no useful function.
•The HIM department must carefully consider the types of filing and storage systems it uses to ensure that they meet the needs of the organization
•The three major classifications of filing systems are discussed below
Alphabetic Filing Systems
•In alphabetic filing systems, records are arranged in alphabetical order
•This system is usually satisfactory for a very small volume of records, such as records maintained in small physician practices
•The alphabetic filing system is easy to create and use
•It is often called a direct filing method because it does not rely on an index or an authority file and the user can find a file by looking directly under the name of the record
What are the disadvantages to alphabetic filing for organizations that have thousands of records?
•First, it does not ensure a unique identifier
•For example, a large facility may have several patients named Paula Smith
•If it were relying strictly on alphabetical filing by patient last and first name, multiple health records would be labeled Paula Smith on the file shelf
What is another disadvantages to alphabetic filing for organizations that have thousands of records?
•A second disadvantage is that alphabetic files do not expand evenly
•Statistically, almost half the files fall under the letters B, C, H, M, S, and W
What is a third disadvantages to alphabetic filing for organizations that have thousands of records?
•A third disadvantage to the alphabetical filing system is that it is time-consuming to purge or clean out files for inactive storage
•With an alphabetical filing system, each individual record needs to be checked for the last patient encounter to determine whether it is inactive (figure 8.3).
Figure 8.3. Rule 1 for alphabetic filing
1.File each record alphabetically by the last name, followed by the first name and middle initial. For example:
Brown, Michelle L.
S. Brown, Robert A.
When the patient has identical last and first names and middle initial, order the records by date of birth, filing the record with the earliest birth date first
Figure 8.3. Rule 2 for alphabetic filing
2. Last names beginning with a prefix or containing an apostrophe are filed in strict alphabetical order, ignoring any apostrophes or spaces.
For example, the names Mackel, Mac Bain, and Mc Dougal would be filed as:
Figure 8.3. Rule 3 for alphabetic filing
3. In hyphenated names such as Manasse-O'Brien, the hyphenation is ignored and the record is filed as:
Numeric filing system
A system of health record identification and storage in which records are arranged consecutively in ascending numerical order according to the health record number
In a numeric filing system, records are filed by:
•Using the health record number
•Numeric filing is a type of indirect filing system
To use an indirect filing system, what must be consulted before the user can identify a record for a specific person?
To use an indirect filing system, an index or authority file needs to be consulted before the user can identify a record associated with a specific patient
What file is usually the master patient index (MPI) in healthcare?
•In healthcare, the authority file is usually the master patient index (MPI)
•The filing clerk searches the MPI by patient name
•When the correct patient is located in the MPI, the clerk uses the health record number to locate the patient's health record folder within the filing system
The numeric filing system is more work than the alphabetic system in which case? When is this not true?
•This can be true for organizations that have a very small number of records (hundreds)
•However, in larger organizations, the numeric filing system actually has many advantages over an alphabetic system
Following are the most common types of Numeric filing systems:
1. In straight numeric filing systems, records are arranged consecutively in ascending numeric order. The number assigned to each file is the health record number
2. The terminal-digit filing system
3. The middle-digit filing system is very similar to the terminal-digit filing system.
Which numeric filing system is considered to be most efficient? The straight or terminal?
•The terminal-digit filing system is considered by many to be the most efficient
•In this system, the last digit or group of last digits (terminal digits) is the primary unit used for filing, followed by the middle unit and the last unit of numbers
•For example, 443798 could be broken down as 44-37-98, with 98 as the primary unit for filing, 37 as the secondary (middle) unit, and 44 as the tertiary unit
•The record would be filed in the following arrangement: file section, 98; shelf number, 37; and folder number, 44. An example of how health records are filed using terminal-digit filing is shown in figure 8.4.
Straight numeric filing systems
A health record filing system in which health records are arranged in ascending numerical order
Terminal-digit filing system:
•A system of health record identification and filing in which the last digit or group of digits (terminal digits) in the health record number determines file placement
•Note: Records first are filed by the last two digits, then the middle two digits, and finally in numerical order by the first two digits
What is the terminal-digit system is excellent for?
•The terminal-digit system is excellent for facilities with a heavy record volume
•This is because large numbers can be divided into groups of several digits and still be easily managed for filing and retrieval purposes
•In addition to ensuring that every record has a unique number, terminal-digit filing allows even file expansion, unlike an alphabetic or straight numerical filing system
The middle-digit filing system
•A numeric filing system in which the middle digits are used as the finding aid to organize the filing system
•The middle-digit filing system is very similar to the terminal-digit filing system
•The primary unit is the middle unit, the secondary unit is the first unit to the left, followed by the last digits
•For example, 443798 could be broken down as 37 as the primary unit, 44 as the secondary unit, and 98 as the tertiary unit
•The record could be filed in the following arrangement: file section, 37, shelf number, 44; and folder number, 98
Although the examples provided above for terminal- and middle-digit filing use a six-digit number, the number of digits in the health record number may vary depending on the healthcare facility:
•The length of any number and how it is divided depends on the organization
•For example, one healthcare facility may have a health record number that is six digits in length
•The highest number or volume of records that could be accommodated in such a numbering scheme would be 999,999 records
•Another healthcare organization may have a numbering system containing seven digits
•The capacity of this facility is much greater and can accommodate 9,999,999 records
•Some facilities may have a three-digit primary unit.
•However, the method for filing would remain the same. The file section corresponding to the primary unit would be accessed first, followed by the secondary unit, and then the tertiary unit.
What are 3 types of filing systems?
Alphabetic Filing Systems
Numeric Filing Systems
Alphanumeric Filing Systems
Alphabetic Filing Systems
•This system uses a combination of alpha letters and numbers for identification purposes
•The first two letters of the patient's last name are followed by a unique numeric identifier
•The alphanumeric filing system is appropriate for small organizations
•Although this system may be quicker because file clerks first file the record alphabetically, it still relies on accessing a master index or authority file to identify the unique numerical number
Centralized Unit Filing Systems
•In a centralized unit filing system, individual patient encounters are filed by the same unique identifier and in the same location
•The unique identifier can be alphabetic, alphanumeric, or numeric
•For example, in a small medical practice all of an individual's encounters may be filed together alphabetically by last name
Usually, centralized unit filing is associated with:
•The unit numbering system in which file clerks have to look in only one location for the patient's health record
•In addition, the supply costs for record folders are reduced because all forms and information are filed together in one folder
•Furthermore, computer or index card update issues are lessened using the unit numbering system
•The patient retains the same health record number, regardless of the number of admissions or encounters.
Check your understanding 8.2:
1. Consider the following sequence of numbers: 12-34-55, 13-34-55, and 14-34-54. What filing system is being used if these numbers represent the health record numbers of three records filed together within the filing system?
B. Terminal-digit filing
Check your understanding 8.2:
2. The master patient index (MPI) is necessary to locate health records within the paper-based storage system for all the types of filing systems, except:
D. Alphabetical filing
Check your understanding 8.2:
3. The term used to describe a combination of paper-based and electronic health records is:
Check your understanding 8.2:
4. Which of the following is an advantage of a centralized unit filing system?
B. One location in which to look for records
Check your understanding 8.2:
5. Which filing system is considered to be the most efficient?
Storage Systems for Paper-based Records: what are the options available?
•Many options are available for storing health records
•Paper-based records are stored in filing cabinets or shelving units
•Other storage options include microfilm, off-site storage, and imaged-based storage
•As healthcare facilities transition toward and implement the EHR, imaged-based systems are increasingly utilized.
The choice of storage systems for paper-based records system depends on:
•The needs of the facility and the amount budgeted within the department for record storage
•For organizations with a high record volume, a combination of systems may be the appropriate choice
•For organizations that have a very low volume of records, paper storage may be appropriate
Filing Cabinets or Shelving Units for storage:
•Paper-based records may be stored in vertical and lateral filing cabinets, open-shelf files, and compressible file systems
•Vertical file cabinets are the traditional drawer files and come in sizes that can hold either letter or legal-sized records
•The usual configuration is two or four drawers
•Vertical file cabinets are appropriate for low-volume record storage
•However, this type of filing equipment does not facilitate quick and easy filing and retrieval
•Therefore, these file cabinets are rarely used to store health records
Lateral filing units for storage:
•Lateral filing units also have drawers
•However, the drawers open laterally rather than vertically
•They also include side-to-side rails for hanging files.
•These filing units range in size from two to five drawers and are usually 30 or 36 inches in width
•Although easier for retrieval and filing than vertical cabinets, this type of equipment would only be used in low-volume offices
The filing equipment of choice for housing health records is usually:
•Some configuration of shelf filing
•Shelf files resemble open bookshelves
•They can either be totally open or have receding doors
•Shelf files are ideal for high-volume record storage
•Shelving units with six shelves are usually used for record storage purposes
•Moreover, shelf files save space
•For example, one six-shelf unit offers file capacity equal to eight 30-inch-wide lateral file drawers
A variation on open-shelf files is:
•A variation on open-shelf files is the mobile or compact file (figure 8.5)
•Instead of having aisle space between every row of files, mobile files conserve floor space by providing only one aisle of space
•This is accomplished by mounting the file shelves on tracks secured to the floor
•The shelves then are moved by hand, with mechanical assistance, or electronically
•This type of storage system is ideal in facilities where space is a major concern
•In most situations, an organization can double or even triple storage capacity in the same floor space, even when compared to other, high-density filing systems such as open shelf
A type of mobile or compact files is the:
•A type of mobile or compact files is the lateral mobile shelving system
•This filing system consists of stationary shelving in the back and file storage shelving that slides side to side in the front
•This is an inexpensive way to increase the storage capacity of existing shelving or another record storage system
•However, this type of shelving is only appropriate for low-volume record filing and retrieval activity
Variations on open-shelf files are:
•Variations on open-shelf files are horizontal and vertical carousel systems
•The horizontal carousel contains open-shelf files that revolve around a central spine or track system
•Essentially, this type of filing system brings the files to the user, thus avoiding walking through aisles of files
•The vertical carousel system brings all files or records to a standing or sitting workstation and can take advantage of vertical ceiling height
•Vertical carousel systems are often used to store the manual MP
What should be considered when determining the type of storage system to use?
The amount of space, volume of records, and record usage or activity must be considered when determining the type of storage system to use.
What happens when there is not sufficient space to house the shelving units?
•When space is not sufficient to house the number of shelving units needed to hold the records for the period of time required for patient care and other purposes, older health records are purged or removed from the file area
How often are records purged?
•Generally, files that have been inactive for a certain period of time (for example, three years since the patient's last visit) are removed from the active filing area
What happens to purged records?
•Purged records are often microfilmed, sent to off-site storage facilities, or scanned
•How frequently paper-based records are purged from the storage system is determined by not only space availability, but also the patient readmission rate and the use of patient record data
•For example, a research hospital may maintain health records in paper format for a period of time longer than other facilities because researchers may need to access information about patients who have expired or who have not been admitted to the facility for a number of years
The volume of health records can be enormous in many organizations. For example:
•When an acute care facility admits 50 patients per day and treats the same number of patients in the emergency department, 100 health records are generated
•Over a year, this amounts to 36,500 new records
•If approximately one inch is required to store five paper records, the organization would need approximately 7,300 inches, or approximately 608 feet, of filing space.
An HIM professional often has responsibility for planning the file space and shelving units required to store paper records. How is this done?
•He or she first must estimate the facility's storage system needs
•This involves analyzing the volume indicators, such as number of discharges, size of the records, and filing inch capacity of the storage unit
•For example, one could estimate the number of shelving units required by using the following information:
Shelving unit shelf width = 36 inches
Number of shelves per unit = 7 shelves
Average record thickness = ½ inch
Average annual inpatient discharges = 8,500 patients
The following demonstrates how the HIM professional would use the information above to estimate the number of shelving units required to house one year's records:
1. Determine the linear inch capacity of each shelving unit
36 inches per shelf × 7 shelves per unit = 252 inches per shelving unit
2. Determine the linear filing inches needed for the volume of records.
8,500 average annual inpatient discharges × ½ average record thickness = 4,250 filing inches required to store one year of inpatient discharge records
3. Determine the number of shelving units required by dividing the required filing space by the shelving unit linear inch capacity.
4,250 ÷ 252 = 16.8 shelving units
How many shelving units would be required to store one year of inpatient records?
•Actually, 17 shelving units would be required to store one year of inpatient records because it is impossible to purchase 16.8 shelving units
•However, most HIM departments store more than inpatient discharge records
What other than inpatient discharge records are stored in most HIM departments?
Outpatient records also are typically stored in the HIM department, and the storage requirements for the outpatient records must be considered when estimating the record storage needs. Consider the following example:
Hospital XYZ has the following volume statistics:
Average inpatient discharges per year = 10,000
Average inpatient record thickness = 1 inch
Average outpatient visits = 22,500
Average outpatient record thickness = ¼ inch
Each shelving unit has 7 shelves, each 36 inches wide
The following demonstrates how the HIM professional would estimate the number of shelving units required to house one year's records:
1. Determine the linear filing inches required to house inpatient and outpatient records.
10,000 inpatient discharges per year × 1 inch = 10,000 linear filing inches required
22,500 outpatient visits per year × ¼ inch = 5,625 linear filing inches required
10,000 + 5,625 = 15,625 linear filing inches needed for inpatient and outpatient records
2. Determine the linear filing inches per shelving unit.
36 inches per shelf × 7 shelves per unit = 252 inches per shelving unit
3. Divide the required filing space by the shelving unit linear inch capacity.
15,625 inches needed ÷ 252 inches per shelving unit = 62 shelving units required to store the records
•Therefore, for this example 62 shelving units would be required to store one year of records
Who does the HIM professional work with to determine the required computer storage space and medium?
In an EHR environment, the HIM professional works with the software vendor and the information technology (IT) department to determine the required computer storage space and medium.
•Paper-based health records that are stored on shelving units, in compressible filing units, or in filing cabinets are housed in filing folders
•During an average inpatient encounter, a health record exceeding 100 pages is common
•These various reports and documents must be sorted and stored in their own file folders. File folders come in two standard weights, 11 and 14 point
•Higher weights such as 20 point are also available
•The higher weight is the most durable and would be the folder of choice for active records that receive heavy filing and retrieval activity.
In addition to weight, consideration for file folders should be given to:
The selection of top or side tabs
How are top and side-tab folders used?
•Top-tab folders are used in vertical or lateral shelving systems
•Side-tab folders, which are the usual configuration for health records, are used in all open-shelf filing systems
Health record folders also should include some type of fastening system to hold the record documents together:
•Record fasteners are two pronged and can be up to 2 inches long
•They can be placed at the top or sides of the file folder
•Usually, folders are purchased with fasteners attached, although for low-volume operations self-adhesive fasteners can be used and installed by office staff
•Dividers also may be placed in health records to separate clinical, inpatient, outpatient, and/or administrative documents
Whether the facility uses an alphabetic or numeric filing system, file folders should be color coded for:
•Color coded for easy filing and retrieval
•For example, in a numeric filing system, each single digit is a specific color
•Therefore, one can easily locate misfiles by visually scanning a shelf for disruption of the color pattern of a particular file shelving section
Figure 8.6 demonstrates the use of color coding on file folders.
•For high-volume systems, color coding of files is done at the factory
•For lower-volume systems, color-coded labels can be affixed to the file folders.
Microfilm-based Storage Systems:
•Storage of paper-based health records consumes an enormous amount of space
•There are other options for record storage that significantly reduce space needs
•A traditional alternative that has been used over the past three or more decades is micrographics or microfilm
•Microfilm is a good storage alternative for inactive or infrequently used health records
How does the microfilming process work?
•Essentially, the microfilming process converts paper documents to archive-stored images by taking a picture of the original document and storing it as a very small negative
•Because the images are so small, a special microfilm viewer or reader that magnifies each image must be used to read them
•This format stores each document page sequentially in a long roll
•One roll of microfilm can potentially hold thousands of images and the health records of hundreds of patients
•However, the fact that the roll stores document pages sequentially can be a disadvantage
•For example, if the organization is using a serial numbering system, a patient's entire health record covering multiple encounters may be on separate roles of microfilm
•This makes retrieval less efficient
•In this format, a roll of microfilm is cut and placed into special four-by-six-inch jackets with several sleeves to hold the images
•A benefit of this option is that all the patient's records can be collected together in the same jacket or several jackets can be combined in a small paper folder
•Thus, the record becomes a unit record holding all information about the patient
•Jackets can be color-coded with the patient's health record number and name. They are usually filed using the same type of filing system (alphabetic, straight numerical, terminal digit) used for paper files
•This format can be a copy of a microfilm jacket or a direct copy of the source health record
•It is made on Mylar film and is the same size as the microfilm jacket •When used as a copy from the source health record, the microfiche eliminates the need to cut rolls of film to fit into microfilm jackets
•Sometimes organizations store their health records in microfilm jackets •These jackets are never removed from the HIM department
•Instead, when the information is needed, a microfiche copy is made using a special duplicator and then provided to the requesting care areas
What are benefits of microfilm?
•One benefit of microfilm is that it is much less costly for backup than digital media
•Moreover, microfilm is acceptable as courtroom evidence and provides good security because it is difficult to tamper with
Why do some facilities use off-site Storage Systems?
Because space for paper-based records has become limited and/or microfilm has become cost prohibitive, many healthcare facilities use off-site storage companies to house purged records
Off-site Storage Systems:
•An off-site storage company is usually a contracted service that stores health records
•The company then retrieves and delivers records requested by the healthcare facility's HIM department for a fee
•The healthcare facility should carefully evaluate the off-site storage company's capabilities for storing records securely for the entire retention period
What are some considerations for off-site storage?
Considerations for off-site storage include climate control, fire protection, pest and dust control, physical protection from burglary or vandalism, and cost
Image-based Storage Systems
•The use of digital document imaging is increasing as healthcare facilities implement EHR or hybrid record systems
•Essentially, a document imaging system scans and indexes an original source document to create a digital picture that can be retrieved via the computer
What do most document imaging solutions include?
•Most document imaging solutions include production scanners that can scan hundreds or thousands of documents a day, plus a workflow or document management application that makes the scanned information available to a department or an entire enterprise
•When scanned, the images are stored on electronic media, such as a magnetic or optical disk
•Unlike microfilm rolls, the optical disk is a random-access device and retrieval of documents is much faster
•Additionally, document images can be viewed by more than one person at one time and at different locations
What is one of the greatest benefits of document imaging?
•One of the greatest benefits of document imaging is increased efficiency by eliminating the requirement to move and track paper documents through workflow •Document imaging also helps solve the problem of lost or misplaced paper or microfiche documents
•Moreover, it saves money by reducing the need for storage space and by decreasing the work of file clerks
Check your understanding 8.3:
1. What type of paper-based storage system conserves floor space by eliminating all but one or two aisles?
C. Mobile filing units
Check your understanding 8.3:
2. What feature of the filing folder helps locate misfiles within the paper-based filing system?
C. Color coding
Check your understanding 8.3:
3. In a paper-based system, the HIM department routinely delivers health records to:
B. Nursing units
Check your understanding 8.3:
4. Which of the following paper weights would be the most durable for the medical record folder?
Check your understanding 8.3:
5. What microfilm format is inefficient when patients have multiple admissions on microfilm?
Retrieval and Tracking Systems for Paper-based Records: What is key to ensuring their accessibility to authorized persons?
Tracking the location of health records removed from a paper-based storage system area is key to ensuring their accessibility to authorized persons.
A device used in paper-based health record systems to track the location of records removed from the file storage area
What is the most common type of tracking system for paper-based health records?
•The outguide is the most common type of tracking system used to track paper-based health records
•An outguide is usually made of strong colored vinyl with two plastic pockets
•It is the size of a regular record folder and is placed in the record location when the record is removed from the file
Description of an outguide:
•Outguides normally come with either a bottom or a middle tab with the word OUT printed on it to indicate that a health record has been removed from the file shelf
•The larger of the plastic pockets is used to hold loose reports or other documents that come to the HIM department while the original record is charged out
•The smaller pocket is used to house information about who checked out the health record, its current location, when it was checked out, and the expected return date
•This checkout information may be either a handwritten or computerized requisition slip generated from a tracking system
•A request from an authorized health record user to gain access to a medical record
•Request from a clinical or other area in the organization to charge out a specific health record
In what form might a requisition be? What information does it contain?
•The requisition may be in paper or electronic form
•The information contained on a requisition usually includes patient's name, health record number, date of the request, date and time needed, name of the requestor, and location for delivery.
How many copies does a requisition slip have in a paper-based system?
•In a paper-based requisition system, the requisition slip has multiple copies
•One copy is the routing slip that comes with the health record
•Another copy goes in the outguide
•A third copy may be used as a transfer notice and sent to the HIM department if the health record is subsequently transferred to another location
•For example, if a record were requested from the intensive care unit (ICU), it would be transferred to the medical unit when the patient was transferred from the ICU to the medical floor
In many institutions, the chart-tracking and requisition systems are built into the automated information system.
•In this case, paper requisition slips are replaced by automated requisitions sent directly to the HIM department and all pertinent data are retained in a database
•Automated systems such as these are similar to a library book checkout system
•With an automated system, it is easy to track how many records are charged out of the HIM department at any given time, their location, and whether they have been returned on the due dates indicated
Figure 8.7 provides an example of how the computer screen appears in a chart-tracking system.
•A barcode representing the health record number is often on the file folder to facilitate data entry into the computer chart-tracking system
•The HIM department should create facility-wide policies and procedures for the proper use of tracking systems •Further, an audit for health records not returned in a timely manner should be performed on a regular basis.
What are some of the tools built into healthcare organizations that use hybrid or EHR systems?
In healthcare organizations that use hybrid or EHR systems, tools built into the systems, such as workflow automation and audit trails, can provide tracking information—for example, who accessed which records and for what purpose
Retention and Destruction of Paper-based Records: an important HIM function is to:
Ensure that there are relevant retention and destruction policies and procedures in place.
An organization's duty of care over health information extends from when?
•An organization's duty of care over health information extends from the time of creation to the time of destruction •Therefore, both health information retention and destruction policies and procedures must be in place
What is recommended good retention practice? What are retention policies?
•It is recommended good practice that retention and destruction policies be approved by the health information manager, chief executive officer, medical staff, malpractice insurer, and legal counsel
•Retention policies and procedures relate to what information must be retained, for how long, and in what form. Destruction policies and procedures relate to what information may be destroyed, appropriate destruction methods, and required documentation of destruction
Why is retention important?
•Established policies and procedures are important to ensure that the healthcare organization is in compliance with appropriate accreditation standards, state statutes, federal regulations, and administrative laws for health information retention
The following are general guidelines recommended for establishing retention policies and procedures (AHIMA 2002a):
•Each healthcare provider should ensure that patient health information is available to meet the needs of continued patient care, legal requirements, research, education, and other legitimate uses.
•Each healthcare provider should develop a retention schedule for patient health information that meets the needs of its patients, physicians, researchers, and other legitimate users, and complies with legal, regulatory, and accreditation requirements
•The retention schedule should include guidelines that specify what information should be kept, the time period for which it should be kept, and the storage medium (paper, microfilm, optical disk, magnetic tape, or other)
The following are general guidelines recommended for establishing retention policies and procedures:
—Compliance programs should establish written policies to address the retention of all types of documentation
•This documentation includes clinical and medical records, health records, claims documentation, and compliance documentation
•Compliance documentation includes all records necessary to protect the integrity of the compliance process and confirm the effectiveness of the program, including employee training documentation, reports from hotlines, results of internal investigations, results of auditing and monitoring, modifications to the compliance program, and self-disclosures
—The documentation should be retained according to applicable federal and state law and regulations and must be maintained for a sufficient length of time to ensure its availability to prove compliance with laws and regulations.
—The organization's legal counsel should be consulted regarding the retention of compliance documentation
The following are general guidelines recommended for establishing retention policies and procedures:
--The majority of states have specific retention requirements that should be used to establish a facility's retention policy
•In the absence of specific state requirements for record retention, providers should keep health information for at least the period specified by the state's statutes of limitations or for a sufficient length of time to prove compliance with laws and regulations
•If the patient was a minor, the provider should retain health information until the patient reaches the age of majority (as defined by state law) plus the period of the statute of limitations, unless otherwise provided by state law
•A longer retention period is prudent, since the statute may not begin until the potential plaintiff learns of the causal relationship between an injury and the care received. In addition, under the False Claims Act (31 USC 3729), claims may be brought for up to 7 years after the incident; however, on occasion, the time has been extended to 10 years
The following are general guidelines recommended for establishing retention policies and procedures:
Unless longer periods of time are required by state or federal law, AHIMA recommends that specific patient health information be retained for established minimum time periods (table 8.2)
Health Information | Recommended Retention Period
Diagnostic images | 5 years
(such as x-ray film)
Disease index | 10 years
Fetal heart monitor records | 10 years after the infant reaches the age of majority
Master patient/person index | Permanently
Operative index | 10 years
Patient health/medical records (adults) | 10 years after the most recent encounter
Patient health/medical records (minors) | Age of majority plus statute of limitations
Physician index | 10 years
Register of births | Permanently
Register of deaths | Permanently
Register of surgical | Permanently
Destruction of records
•Record destruction, should only be done in accordance with federal and state law and written retention and destruction policies of the organization
•Furthermore, records involved in any open investigation, audit, or litigation should not be destroyed
What do some states require for record destruction?
•Some states require creation of an abstract, notification of patients, or specify the method of destruction
In the absence of any state law to the contrary, AHIMA recommends the following guidelines for destruction of health information (AHIMA 2002b):
•Destroy the records so there is no possibility of reconstruction of information
—Appropriate methods for destroying paper records include burning, shredding, pulping, and pulverizing
—Methods for destroying microfilm or microfiche include recycling and pulverizing
—The laser disks used in write once-read many (WORM) document imaging applications cannot be altered or reused, making pulverization an appropriate means of destruction
—The preferred method for destroying computerized data is magnetic degaussing
•(Data are stored in magnetic media by making very small areas called magnetic domains change their magnetic alignment to be in the direction of an applied magnetic field
•Degaussing leaves the domains in random patterns with no preference to orientation, rendering previous data unrecoverable.)
•Proper degaussing ensures that there is insufficient magnetic remanence to reconstruct the data. Overwriting can also be used to destroy computerized data. (To overwrite, cover the data with a pattern, its complement, and then another pattern—for example, 00110101, followed by 11001010, and then 10010111.)
•In theory, however, files that have been overwritten as many as six times can be recovered. Total data destruction does not occur until the original data and all backup information have been destroyed
—Although magnetic tapes can be overwritten, it is time consuming and there can be areas on a tape that are unresponsive to overwriting
•Degaussing is considered preferable
In the absence of any state law to the contrary, AHIMA recommends the following guidelines for destruction of health information (AHIMA 2002b):
Document the destruction, including:
—Date of destruction
—Method of destruction
—Description of the disposed records
—Inclusive dates covered
—A statement that the records were destroyed in the normal course of business
—The signatures of the individuals supervising and witnessing the destruction
In the absence of any state law to the contrary, AHIMA recommends the following guidelines for destruction of health information (AHIMA 2002b):
•Maintain destruction documents permanently
•These are called certificates of destruction
•Such certificates may be required as evidence to show records were destroyed in the regular course of business
•When facilities fail to apply destruction policies uniformly or where destruction is contrary to policy, courts may allow a jury to infer in a negligence suit that if records were available, they would show the facility acted improperly in treating the patient
•Figure 8.8 provides an example of a certificate of destruction
If destruction services are contracted, the contract must meet the requirements of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. In addition, the contract should:
—Indemnify the healthcare facility from loss due to unauthorized disclosure
—Require that the business associate maintain liability insurance in specified amounts, at all times the contract is in effect
—Provide proof of destruction
—Specify the method of destruction
—Specify the time that will elapse between acquisition and destruction of data
Certificate of destruction:
A document that constitutes proof that a health record was destroyed and that includes the method of destruction, the signature of the person responsible for destruction, and inclusive dates for destruction
What should the method of destruction be based on?
The method of destruction should be reassessed annually, based on current technology, accepted practices, and availability of timely and cost-effective destruction services
Check your understanding 8.4:
1. Under the False Claims Act, claims may be brought up to how many years?
C. Generally 7 years, but could go as high as 10
Check your understanding 8.4:
2. Record retention should be based on:
D. State regulations and AHIMA recommendations
Check your understanding 8.4:
3. Which of the following is the appropriate method for destroying microfilm?
Check your understanding 8.4:
4. Which of the following is the appropriate method for destroying computerized data?
Record Processing of Paper-based Records:
Record processing refers to the procedures performed that support the maintenance of each individual patient record in an organized and standard manner.
What does the record processing of paper-based records facilitate?
•This function facilitates efficiency, accuracy, and completeness of the health record
•The quality of patient care is adversely affected when complete and correct information is not readily available for delivery of patient care
•Moreover, administrative and other functions, such as evaluating clinical quality performance, billing, and research, would be negatively affected without a complete and accurate health record
•The following activities are normally considered record processing.
Admission and Discharge Record Reconciliation for Paper-based Records:
In a paper-based record environment, when a patient is admitted to the healthcare facility, the HIM professional will search the MPI to see if the patient has had any previous admissions to the facility.
If a patient has a previous admission, what happens with the health records?
The health records from the previous admission(s) may be retrieved from the permanent storage area and delivered to the patient care unit for the medical staff to reference the patient's past medical history.
once the patient is discharged from the healthcare facility, what happens with the health record?
•Once the patient is discharged from the healthcare facility, the health record of each patient discharged is either retrieved by the HIM professional or delivered to the HIM department for record processing
•However, before health records can be processed, the HIM professional must assure that all health records for patients discharged on that date have been received
•The health records received by the department are compared to a discharge list, which is usually generated from the hospital's registration system
•The process of assuring that all the records of discharged patients have been received by the HIM department for processing is called record reconciliation
The process of assuring that all the records of discharged patients have been received by the HIM department for processing
What happens if a health record of a discharged patient has not been received by the HIM department?
•The HIM professional must locate the health record
•The chart-tracking system is updated to reflect that old records have been returned and filed in the permanent file area
•The current records of discharged patients are then sent to the health record processing area
Record Assembly Functions for Paper-based Records
¶In a paper-based system, the health record is organized or "assembled" after the patient is discharged from the hospital or other setting
•Assembly means that each page in the patient record is organized in a pre-established order
•The pre-established record order of the pages varies from facility to facility
•Each page in the patient record is reviewed to ensure that it belongs to that record
Deficiency Analysis for Paper-based Records:
After the record is assembled in the correct order, HIM professionals review or "analyze" it to make sure that there are no missing reports, forms, or required signatures and that all documents contain the patient's name and health record number. This review for deficiencies is an example of quantitative analysis
The quantitative analysis or record content review process can be handled in a number of ways.
1. Concurrent review
2. Retrospective review
•Some acute care facilities conduct record review on a continuing basis during a patient's hospital stay
•Using this method, personnel from the HIM department go to the nursing unit daily (or periodically) to review each patient's record
•This type of process is usually referred to as a concurrent review because review occurs concurrently with the patient's stay in the hospital
•Other acute care facilities perform the quantitative analysis the day following the patient's discharge from the hospital
•This type of review is called retrospective review because it occurs after the patient has left the facility
•In this process, the patient's health record is received in the HIM department, usually the day after discharge, and reviewed by an HIM professional
•The part of the utilization review process that concentrates on a review of clinical information following patient discharge
Whether done concurrently or retrospectively, the review usually involves checking to ensure that:
•All forms and reports contain correct patient identification (name, health record number, gender, attending physician, and so on)
•All forms and reports are present. For example, when the patient is admitted for a cholecystectomy, a minimum set of operative reports, consents, and forms should be present (operative consent form, anesthesia form, operative report, recovery room report, pathology report, and so on)
•Reports requiring authentication (that is, operative, pathology, discharge summaries, history and physicals, and radiology reports) have signatures or have been appropriately authenticated
A device for tracking information (for example, reports) missing from a paper-based health record
When deficiencies are identified:
•The HIM professional usually completes a deficiency slip that indicates what reports are missing or require authentication and enters this information into a computer system that logs and tracks health record deficiencies
•See figure 8.9 for a sample paper deficiency slip
•Usually, the deficiency slip is a multipart form, one copy appended to the health record and one or more copies filed by physician name
•A record with deficiencies is called an incomplete record
Automated systems for tracking record deficiencies are commonly used to facilitate what?
•Automated systems for tracking record deficiencies are commonly used to facilitate the deficiency process
An automated health record deficiency tracking system has:
A computer screen that looks similar to the deficiency slip to allow for data entry (figure 8.10).
What happens in the event an automated deficiency system is utilized?
•Each deficiency for a specific record is entered into the computer as is the name (or identification number) of the physician responsible for completing the deficiencies
•This type of system stores the entered data into a database for later retrieval or analysis
What are benefits to automated deficiency systems?
•Such systems reduce the amount of clerical work, make retrieval of deficiency information faster and easier, and provide for automatic report and statistics generation about deficiencies
•When deficiencies are identified and documented, they must be corrected. When reports or forms are missing, HIM personnel should try to locate them.
The health record content review
•Its requirements and how extensive it is •Depends on the individual organization and its medical staff bylaws, rules, and regulations as well as on licensing and accreditation body requirements
•Other inpatient facilities, such as long-term care and rehabilitation institutions, usually follow the same processes as acute care facilities
•Outpatient facilities such as clinics or physician office practices usually conduct a quantitative analysis after each patient visit or on a periodic basis
"Loose" report or "loose" filing:
•Reports that the HIM department often receives belonging to a health record that has already been assembled or scanned. •These unprocessed reports are called "loose" reports or "loose" filing
•In a paper-based system, the medical record must be located and the loose report assembled into the appropriate location within the record
Monitoring Completion of Paper-based Records: What happens when deficiencies in the health record are identified through quantitative analysis?
When deficiencies in the health record, such as reports that need to be dictated or signed by a physician or other health professional, are identified through quantitative analysis, the record is filed in a specially designated area of the HIM department, frequently called the incomplete record file.
What happens after deficiencies in the health record are identified through quantitative analysis and the record is filed in the incomplete record file?
•A copy of the deficiency slip also is filed, usually by the name of the responsible healthcare professional
•Periodically, the HIM department notifies the appropriate individuals of the incomplete or deficient record status and requests that they come to the department to rectify it
•In the EHR environment, or where electronic signatures and electronic authentication of medical records is accepted, the incomplete record file may be eliminated.
After the healthcare professional completes the record deficiencies, what is done with it? What happens if no deficiencies are found?
•The record is reanalyzed to ensure its completeness
•If no deficiencies are found, the deficiency slip is removed and/or the deficiency tracking system is updated to reflect that the health record is completed
•The health record then is routed to the storage and retrieval area for filing in the permanent file
An incomplete record not finished or made complete within the time frame determined by the medical staff of the facility
Monitoring Completion of Paper-based Records: what is a record considered when an incomplete record is not rectified within a specific number of days as indicated in the medical staff rules and regulations?
The record is considered to be a delinquent record.
At what point is an incomplete record considered delinquent? Who monitors the delinquent record?
•Generally, an incomplete record is considered delinquent after it has been available to the physician for completion for 15 to 30 days
•The HIM department monitors the delinquent record rate very closely to ensure compliance with accrediting standards that define performance expectations or processes that must be in place
Handling Corrections, Errors, and Addendums in Paper-based Records: Integrity and written policies
•Health records may occasionally require that entries be amended, corrected, or deleted
•Regardless of the media used to store the health record, policies must be in place to assure the integrity of the information contained in the health record as a business record, legal health record, and as a patient care communication tool •The healthcare facility must have written policies that specify who, when, and how amendments, corrections, and deletions may be made to a health record
Corrections: how are they made in a paper-based health record environment?
•In a paper-based health record environment, corrections to health record entries are corrected by drawing a single line through the original entry, writing "error" above the entry, and then the practitioner signs, dates, and times the correction
•Error: correction "female" Jane Smith, MD 12/11/09 15:00
•The 72-year-old white male presents to the emergency room with a 4-hour history of severe lower right quadrant abdominal pain
•An addendum is a supplement to a signed report that provides additional health information within the health record
•In this type of correction, a previous entry has been made and the addendum provides additional information to address a specific situation or incident
The following guidelines should be followed for making addendums (AHIMA e-HIM Workgroup on Maintaining the Legal EHR 2005):
•Document the current date and time
Write "addendum" and state the reason for the addendum, referring back to the original entry
•Identify any sources of information used to support the addendum
•When writing an addendum, complete it as soon after the original note as possible
•An amendment is a clarification made to the health information after the original documentation has been final signed by the provider
•An amendment must be dated, timed and signed and attached to the original document that it is amending (Hall et al. 2009)
Authorization and Access Control for Paper-based Records
"Access control is the process that determines who is authorized to access patient information in the health record" (AHIMA Workgroup on Electronic Health Records Management 2004).
What does access control involve?
•Access control involves determining which individuals or groups should be granted access, what portions of the health record should be available, and what rights should be granted
•For example, HIM professionals responsible for release of information would be granted the right to print the EHR or copy the paper record, whereas a nurse or physician would be granted view-only access to the EHR
•Physicians and nurses would be granted the right to enter patient information in the EHR
For the paper portion of the health record, what is the process the HIM staff performs to verify the identity of person requesting access?
•Authentication is the process the HIM staff performs to verify the identity of the person requesting access and determining if that person is authorized to access the record
•Checking a photo identification card (for example, employee identification card) is one example of authentication of the person's right to access the paper-based health record
•Access cards may also be used to authenticate the user's right to access the record system
•Access cards are often used in combination with passwords or personal identification numbers (PINs) as a method of authenticating the person's identity (AHIMA Workgroup on Electronic Health Records Management 2004)
Forms Design, Development, and Control for Paper-based Records: what is an important part of ensuring adequate health record content?
•An important part of ensuring adequate health record content is the function of forms design and development
•In a paper record system, forms make possible the capture of adequate healthcare documentation
•The HIM department often participates in forms design in consultation with a forms vendor
What is the basic concept behind any form? What does this mean?
•The basic concept behind any form is that it must meet the needs of the end user
•This means that the form must fulfill its intended purpose, include all the necessary data, and be easy to use
Forms Design and Development: first steps in forms design:
•One of the first steps in forms design is to identify the purpose, use, and potential users of the form
•This basic information will drive the rest of the design process
•For example, when the purpose of the form is to meet a licensing requirement, the data elements contained on it must comply with the requirement
•When the form is to be used by multiple individuals, a multicopy version might be appropriate. When it is to be completed by hand, it must allow enough space for handwriting
What is important to ensure after the purpose, use, and potential users of a form have been identified?
After the purpose, use, and potential users of the form have been identified, it is important to ensure that the new form does not duplicate one already in place. Organizations often needlessly duplicate forms because they have no mechanism for forms tracking
Any forms design project should follow a number of guidelines. The following are common design elements for paper forms (AHIMA 1997):
•All forms should contain a unique identifying number for positive identification and easy inventory control.
•Each form should include original and revised dates for the tracking and purging of obsolete forms.
•Each form should have a concise title that clearly identifies the form's purpose.
•The facility's name and logo should appear on each page of the form.
•For clinical forms, patient identification information (name, health record number, billing number, physician name and number, date of birth, admission date, and room number) should appear on every page.
•For clinical forms, a signature line should appear at the bottom, and there should be no question about what has been authenticated. If initials are used, space also should be provided for the full name and title so that each set of initials is identified
•Data-entry methodology should be considered when the information is to be keyed into a computer. The order of the form should mirror the data-entry order to ensure that information is entered consistently.
•Optical character reader codes and barcodes should be printed in the upper left-hand corner of the form when imaging the health record is a possibility.
•A standard of 8.5 by 11 inches is the best size for a document. Bifold and trifold documents are difficult to handle and copy in a closed chart.
•Form colors should be black ink on white paper. If color coding is desired, a strip of •Documents that contain punched holes should have a margin of at least 3/4 inch. All other margins should be at least 3/8-inch wide.
•Vertical and horizontal lines assist the user in completing and reviewing the form. Bold lines should be used to draw the reader's eye to an important field.
•Sufficient space should be provided to complete the entry (for example, 1/16 inch for typed letters and 1/3-inch high for handwritten entries).
•Titles for boxes and fields should be located in the top left-hand corner of the box or field.
•Paper ranging from 20 to 24 pounds in weight is recommended for use in copiers, scanners, and fax machines.
•Type size should be no smaller than 9 points for lowercase letters and 10 points for uppercase letters
The principles of good design are critical when:
•The principles of good design are critical when forms are used in document imaging systems
•For example, the use of colored paper or ink other than black should be minimized or eliminated because the color can adversely affect the quality of the scanned images
The use of scanned images requires forms to contain? Forms without a barcode must be what?
•Also, the use of scanned images requires forms to contain a barcode that identifies the document type, thus enabling the form to be placed in the proper location within the EHR
•Forms not containing a barcode must be indexed separately when scanned into the computer
Clinical Forms Committee
•Every healthcare organization should have a forms or design (for EHR systems) committee
•The medical records committee also may function in this capacity
•This committee should provide oversight for the development, review, and control of all enterprise-wide information capture tools, including paper forms and design of computer screens
The committee should be composed of information users and include representatives from the following:
Health information management
Support or ancillary departments
Forms vendor representative
Anyone directly affected by the new form or computer view should be invited to attend?
•In addition, anyone directly affected by the new form or computer view should be invited to attend the forms committee meeting
•For example, when a form is being redesigned for use in the intensive care unit, nurses or physicians from that clinical area should be invited to give their input
Forms Control, Tracking, and Management: At a minimum, a good forms control program includes the following activities (Barnett 1996):
1. Establishing standards:
•Written standards and guidelines are essential to ensure that good design and production practices are followed
•A forms manual should be developed. Standards are fixed rules that must be followed for every form (for example, where the form title should be located)
•A guideline, on the other hand, provides general direction about the design of a form (for example, usual size of the font used)
2. Establishing a numbering and tracking system:
•A unique numbering system should be developed to identify all organizational forms
•A master form index should be established, and copies of all forms should be maintained for easy retrieval
•At a minimum, information in the master form index should include form title, form number, origination date, revision dates, form purpose, and legal requirements. Ideally, the tracking system should be automated
3. Establishing a testing and evaluation plan:
•No new or revised form should be put into production or use without a field test and evaluation
•Mechanisms should be in place to ensure appropriate testing of any new or revised form
4. Checking the quality of new forms:
•A mechanism should be in place to check all newly printed forms prior to distribution
•This should be a quality check to ensure that the new form conforms to the original procurement order.
5. Systematizing storage, inventory, and distribution:
•Processes should be in place to ensure that forms are stored appropriately
•Paper forms should be stored in safe and environmentally appropriate environments
•Inventory should be maintained at a cost-effective level, and distribution should be timely
6. Establishing a forms database:
•In an electronic system that supports document imaging, a forms database may be used to store and facilitate updating of forms
•Such a database can provide information on utilization rates, obsolescence, and replacement of individual forms or documentation templates
Quality Control Functions in Paper-based Systems: all the him functions in this section must be managed appropriately to do what?
All the HIM functions discussed in this section must be managed appropriately to ensure the quality of health record content as well as the security, accessibility, and timeliness of the information contained in the health record.
Does having a process for health record review ensure content quality? Does having good forms design practices mean all forms developed are necessary?
•However, merely having a process for health record review does not totally ensure content quality
•Further, having good forms design practices does not necessarily mean that all forms that are developed are necessary
If not all forms developed are necessary, what must the organization establish?
•Therefore, the organization must establish systems to help monitor and control the quality of record content and processes
•The strategies discussed thus far help ensure quality control over the management of health record content
In addition to quality monitoring performed to ensure compliance with Joint Commission standards, HIM functions should be?
•Monitored for accuracy and timeliness
Examples of control measures that may be established to ensure that processes are being performed correctly and that systems are functioning as expected:
•The department should establish standards and criteria that indicate an acceptable level of performance
•After quality control standards are established, it is important to establish a monitoring system to determine whether goals are being met
•Corrective action should be implemented when error or accuracy rates are deemed to be at an unacceptable level. Chapter 11 describes specific techniques and quality improvement practices
Storage and Retrieval: Various standards can be set to monitor the quality of the storage and retrieval process
•Filing accuracy can be checked by conducting a random audit of the storage area
•To conduct a study, a section of the permanent file room can be checked for misfiles
•Any misfiles found are noted, and a filing accuracy rate can be determined and compared against the established standard
•For example, if the standard is that "99 percent of the health records will be filed correctly," a sample of filed records can be checked for misfiles
•If 550 health records are checked and 7 misfiles are found, the error rate is 1.27 percent (7 divided by 550 multiplied by 100, which would make the accuracy rate 98.7 percent)
What is the rechecking process? What should be done to run checks in a digital imaging system?
•Some organizations have a rechecking process whereby a record is filed and tagged and another employee follows up and checks the accuracy of the filing. •Similarly, in a digital imaging system, indexing and quality should be checked through a defined quality assessment process to ensure the retrievability of health information
Timeliness of the storage and retrieval processes also can be monitored. Examples of standards that may be established to determine the timeliness of HIM services are:
•An average of 50 records will be filed in an hour
•Records for the emergency department will be retrieved within 10 minutes of the request
•Loose materials will be filed in either the record or the outguide pocket within 24 hours of receipt in the HIM department
•An average of 190 pages of scanned records will be indexed in an hour
•Scanned records will be available online within 24 hours of discharge
Record Processing: In a paper-based health record system, how do physician's complete records?
•In a paper-based health record system, physicians come to the incomplete record area to dictate and sign medical records
•If records are unavailable when they arrive, the chart completion process is delayed
How can the availability of records be monitored?
•The availability of records can be monitored by comparing the incomplete chart lists for a sample of physicians against the charts available to the physicians when they come to the HIM department
•For example, if seven physicians worked on completing charts on a particular day with a total of 210 incomplete records collectively and a total of 35 charts were not available, the nonavailable chart rate is 16.6, or 17 percent (35 divided by 210 multiplied by 100)
Check your understanding 8.5:
1. What should be done when the HIM department's error or accuracy rate is deemed unacceptable?
A. A corrective action should be taken
Check your understanding 8.5:
2. The forms design committee:
A. Provides oversight for the development, review, and control of forms and computer screens
Check your understanding 8.5:
3. Statements that define the performance expectations and/or structures or processes that must be in place are:
Check your understanding 8.5:
4. In a paper-based system, individual health records are organized in a pre-established order. This process is called:
Check your understanding 8.5:
5. Reviewing a health record for missing signatures and missing medical reports is called:
Check your understanding 8.5:
6. Reviewing the record for deficiencies after the patient is discharged from the hospital is an example of what type of review?
Check your understanding 8.5:
7. Incomplete records that are not completed by the physician within the time frame specified in the healthcare facility's policies are called:
B. Delinquent records
Instructions: Indicate whether the following statements are true or false (T or F):
8. __F__ In a paper-based record, errors should be completely obliterated.
9. __F__ Addendums should document the date the event actually happened—not the date it was documented.
10. _T___ The best practice for forms design is to use white paper with black ink
HIM Functions in a Hybrid Environment: The hybrid record comprises:
•The hybrid record comprises individually identifiable data, in any medium, that are collected, processed, stored, displayed, and used by healthcare professionals
•For example, dictation, laboratory, and x-ray results might be available electronically, whereas progress notes, ancillary care, provider information, graphic sheets, and doctors' orders remain on paper
Other health information may be maintained on various other media types such as? How is the information collected/used?
•Film, video, or an imaging system
•This information in the health record is collected and/or directly used to document healthcare delivery or healthcare status
What is a hybrid record?
•The hybrid record is a transitional health record that at some point becomes an electronic health record
Percentage of paper-based components? What are the first components to be accessible electronically?
•The percentage of paper-based components and electronic components varies from facility to facility
•Dictation or transcription, laboratory results, and radiology reports are often the first components to be accessible electronically
Imaging functions that comprise the electronic document management systems are:
•Imaging functions that comprise the electronic document management systems are the often utilized as the hybrid record evolves toward becoming an EHR
The Theory into Practice case at the beginning of this chapter is an example of:
•The Theory into Practice case at the beginning of this chapter is an example of the transition from a paper-based to a hybrid record environment
•The following sections describe in additional detail the management of the hybrid record
The intent of record Storage, Retrieval, and Retention of Hybrid Records vs. paper-based:
•Although the intent of storage, retrieval, and retention functions for hybrid records are the same as for paper-based systems, how the functions are carried out may differ
•This is due in part to the different media and technologies used that require different work functions and workflow patterns
The intent of record Storage, Retrieval, and Retention of Hybrid Records vs. paper-based: Use of Electronic Document Management Systems (EDMS):
•One commonly used system in the hybrid environment is an electronic document management system (EDMS)
•An EDMS encompasses a wide range of technologies used to provide portions of an electronic health record and does more than manage documents after they are scanned into the computer
What functions does a robust EDMS perform?
Among these are:
•Scanning a paper document and creating a digital image
•Using workflow management technologies to schedule and monitor work tasks
•Using multimedia technologies and formats and using technology to move computer generated content such as a history and physical or discharge summary from a transcription system to an EDMS without creating paper
In a hybrid record environment the document imaging component is often used to:
Make paper-based records electronically accessible post-discharge. See figure 8.11 for an example of an EDMS that is used as a chart repository to provide electronic access to the hybrid record.
What are some components of the health record that may be electronically transmitted to the EDMS via computer interfaces and computer output to laser disk (COLD) fed documentation?
•Medical transcription, laboratory results, and radiology results are most often electronically transferred to the EDMS. •Some facilities also have components of the nursing documentation and ancillary healthcare documentation captured at the point of care and sent directly to the EDMS
•Figure 8.12 provides a checklist of key steps in the planning process for an EDMS
Figure 8.12. Checklist for planning an EDMS: 1. Assembly
1. Assembly: Ensure the record is in the optimal physical order for efficient processing for records to be scanned
Figure 8.12. Checklist for planning an EDMS: 2. Types of records:
2. Types of records: Determine where each of the following is stored and how reconciliation will occur on a daily basis (check in and account for each chart, even outpatients)
Figure 8.12. Checklist for planning an EDMS: 3. Forms inventory/format
3. Forms inventory/format: Create inventory with sample of each form.
Figure 8.12. Checklist for planning an EDMS: 4. Loose/late reports:
4. Loose/late reports: Determine policy on receipt of loose reports, adding in order or filing in back of chart, and codifying once entered into system
Figure 8.12. Checklist for planning an EDMS: 5. Physical layout of equipment:
5. Physical layout of equipment: Determine workflow in HIM department.
Figure 8.12. Checklist for planning an EDMS: 6. Analysis, deficiency, and electronic signature process:
6. Analysis, deficiency, and electronic signature process: Ensure that the medical record is complete and that entries are timely according to established rules and regulations
Figure 8.12. Checklist for planning an EDMS: 7. Paper storage/filing:
7. Paper storage/filing: Determine disposition of paper documents after scanning
Figure 8.12. Checklist for planning an EDMS: 8. Communications:
8. Communications: Ensure that all stakeholders receive critical information about the new system and the impact.
Figure 8.12. Checklist for planning an EDMS: 9. Quality assurance:
9. Quality assurance:
•Index and perform quality control after documents are scanned
•Indexing is performed to assign document names and encounter numbers to each document
•Quality control is performed on 100 percent of images to review the quality of the scan
•In addition to this initial quality control, ongoing quality monitoring should be performed on a random basis
Figure 8.12. Checklist for planning an EDMS: 10. Policy and procedures:
10. Policy and procedures: Develop new policy and procedures
Figure 8.12. Checklist for planning an EDMS: 11. Legal considerations:
11. Legal considerations:
•The information stored is the entity's business record (in healthcare, the legal record)
•A plan to house this information on media other than paper must be scrutinized by legal counsel to ensure that the technology being considered can comply with federal and state laws, requirements for licensure, and credentialing along with operational needs and that it is consistent with existing policies and procedures
•There should also be a risk management component to ensure that there will be no compromise to patient care and that documents required for lawsuits remain available
•This latter consideration may impact a facility's decision on how to proceed with their documents once scanned into the imaging system
Workflow Using an EDMS: The workflow in the hybrid record environment is similar to paper-based health records with the following exceptions:
1. The permanent storage and retrieval areas are replaced with electronic storage of imaged records
2. The incomplete record area resides in the EDMS
3. Medical coding may be done remotely
The paper-based record assembly process described earlier is replaced by:
Record preparation and document scanning in the hybrid and EHR environment.
Records are prepared for scanning by:
•Repairing torn forms, removing staples, and adding header forms to the front of the records
•Additionally, checks are made to ensure that all pages are identified accurately as part of the individual patient's record •Depending on the extent to which barcoded forms are used, the record may still need to be assembled to ensure proper order by date and type of report. •The record is then scanned using highspeed scanners
Following is an example of the workflow post-discharge steps 1-10 in a hybrid record system where a EDMS is utilized:
1. Paper record is retrieved from the patient care unit.
2. Record receipt is reconciled with the list of patients discharged for that date.
3. Records are prepared by removing staples, clips, and repairing torn pages.
4. Each page of the record is checked to verify that it does indeed belong to that patient
5. Record is scanned into the EDMS.
6. The quality of the scanned image is reviewed. If the image is not of high quality, the image is enhanced or rescanned
7. Forms missing a barcode are indexed and placed into the proper location within the health record
8. Records are analyzed for missing documents (for example, discharge summaries, operative reports, history and physicals, and so forth)
9. Records are analyzed for missing signatures. Deficiencies are electronically tagged
10. The record is sent to an "incomplete" work queue for the physician to complete.
Following is an example of the workflow post-discharge last steps 11-13 in a hybrid record system where a EDMS is utilized:
11. Records are also placed in a coding queue to await coding.
12. When the record is completed, it is locked to prevent further changes to the health record
13. Scanned paper records are boxed or sent to storage and kept for the period specified in the record retention policy.
What is an advantage in using an EDMS?
An advantage in using an EDMS is that it can help manage work tasks
Workflow rules built into the system automatically do what?
•Workflow rules built into the system automatically identify the work tasks to be performed, how they should be routed, and sequences and dependencies among tasks
•For example, in management of record completion, as the status of dictation changes from dictate to transcribe to sign to signed, the status of the deficiency system is automatically updated without human intervention
•At the same time, a request for dictation or review and signature is routed to the physician's in-box
The use of an EDMS also allows:
Tasks to be performed in secure locations outside the facility. Primary examples include coding and transcription functions
Record Retention: what is hybrid record environment similar to? What must be considered?
•Retention of health records in a hybrid record environment is similar to those for health records in a paper-based environment
•The healthcare facility must consider state and federal regulations, statutes of limitation, research and educational needs, and patient care needs
Record retention: Special consideration must be given to:
•Special consideration must be given to how long to keep paper records that have been scanned into the EDMS
Record retention: Facility quality checks assure what? Facilities must have a policy on how long the paper portion of the imaged record is?
•Facilities have several quality checks integrated in the record processing function, to assure that the best possible image is included in the electronic portion of the health record
•The facility must have a policy on how long the paper portion of the imaged record is maintained after the record is complete
In regard to length of time paper records are stored, the AHIMA e-HIM Workgroup on Electronic Document Management as a Component of EHR (2003) states:
•As a general rule, paper records should be boxed up after all paper is scanned, indexed and released in the EDMS, stored for no longer than six months and then destroyed."
•Other facilities may decide to maintain the paper records of imaged documents for longer or shorter periods of time
•The storage capacity, the cost, and the definition of the facility's legal record will determine how long these paper records are maintained.
When the hybrid records include paper records that are not imaged, this should be indicated in the EDMS. For example:
•Fetal monitoring strips are often cumbersome to scan because they are a continuous feed of paper
•The decision may be made by the facility to maintain the fetal monitoring strips and other like documents on paper and store them within the facility
•The location and existence of these paper portions of the record must be noted in EDMS
Handling corrections, health records: regardless of the media used to store the health record, policies must be in place to assure what?
•As noted earlier, health records may occasionally require that entries be amended, corrected, or deleted
•Policies must be in place to assure the integrity of the information contained in the health record as a business record, as a legal health record, and as a patient care communication tool
What do a facilities policies regarding corrections specify?
The healthcare facility must have written policies that specify who, when, and how amendments, corrections, and deletions may be made to a health record
What will the way corrections are handled in a hybrid record environment depend upon?
•The way corrections are handled in a hybrid environment depend on how the documentation is created
•If the record is in paper format then the guidelines discussed earlier under paper-based systems apply
•If the record is in an electronic format then the guidelines discussed in the following section under electronic record systems apply
•Records stored in EDMSs present unique situations for handling corrections
If the record is stored in an EDMS then the following guidelines should be followed:
Corrections: Policies should identify? Guidelines for changes should be made to what kinds of documents?
•Policies and procedures should identify how and by whom corrections are made. Business rules may apply that identify who can access and correct unsigned documents
•Facilities should develop guidelines for changes made to signed and unsigned documents
•For example, if a document is changed or corrected, typically the copy with the error is removed from view within the EDMS
•However, a copy of the original document must be available. This can either be a manual or electronic process •It is important that all staff are aware that these documents are available. Some type of annotation may be made in the EDMS system so that clinical staff will know who to contact if they feel they may need to see the original document
•Retraction involves removing a document from standard view, removing it from one record, and posting it to another within the electronic document management system
•In the record from which the document was removed, the document would NOT be considered part of the designated record set or visible to anyone
•Someone should be designated by the organization to view or print the retracted documents
•An annotation should be viewable to the clinical staff so that the retracted document can be consulted if needed.
Involves moving a document from one place to another within the same episode of care. No annotation of this action is necessary.
Reassignment (synonymous with misfiles):
•Involves moving the document from one episode of care to a different episode of care within the same patient record
•As with retractions, someone in the organization should be designated to view or print the reassigned document
•An annotation should be viewable to the clinical staff so that the reassigned document can be consulted if needed
Search, Retrieval, and Manipulation: In a hybrid record environment, health data include? What is the goal of the hybrid record system?
•Both paper and electronic documents and use both manual and electronic processes
•The goal of the hybrid record system is to enable retrieval of information to assist healthcare professionals in providing quality patient care and reporting patient outcomes
Where should it be indicated when the hybrid record includes paper records that are not imaged? What will the facility have to rely on in these cases?
•This should be indicated in the EDMS
•In these cases the facility will have to rely on usual paper-based location identification and retrieval processes.
Within the EDMS, how may documents be retrieved in various ways, and what does the method used depend upon? How is it ensured that the right information is delivered?
•The method used depends upon how the EDMS has been installed and configured
•For example, retrieval could be through the organization's intranet, the Internet, an application on the desktop, or within the clinical system
•Access should be integrated so that the end user does not have to move between various systems
•To ensure that the right information is delivered to the right person, the system should provide basic and advanced search methods that include filters as well as security measures that track access and limit access on a need-to-know basis
The facility should have distribution policies in place to safeguard the information. Among the policies that should be established are:
•Online viewing for authorized users, •Online viewing and printing (usually limited to HIM staff to support release of information functions), and
•Auto fax for authorized users
For security and privacy reasons retrieval and viewing of information should be done where? What should be provided to authorized viewers? What does this viewing include?
•Designated work areas throughout the organization
•Remote viewing should be provided to authorized individuals and should use customary security processes for remote access
•Remote viewing may include viewing documents from physician offices and for remote record completion or remote coding to name a few instances
Limits an EHR's user's ability to deny (repudiate) the origination, receipt, or authorization of a data exchange by that user
Authorization and Access Control for Hybrid Records: what must be addressed in hybrid record access?
•As stated earlier, "Access control is the process that determines who is authorized to access patient information in the health record" (AHIMA Workgroup on Electronic Health Records Management 2004)
•Since the hybrid record is comprised of both paper and electronic components, the healthcare facility must address authorization to access both the paper and electronic portions of the record.
How is access controlled for the electronic portion of the health record? What is the most common method? How is this access strengthened?
•For the electronic portion of the health record, authentication is the process that the computer goes through to assure that the person accessing the system is an authorized user
•The most common method of authentication is the use of user names and passwords
•Access control is strengthened by the use of "strong" passwords that include numbers, upper- and lowercase letters rather than easily identifiable names or numbers
What are paper based methods of record access control?
As stated earlier, for paper portions of the health record, checking a photo identification card, access cards, or a combination of passwords or personal identifications numbers are methods for authentication
What do nonrepudiation measures do? What is an example of a nonrepudiation measure?
•Nonrepudiation measures "limit an EHR's user's ability to deny (repudiate) the origination, receipt, or authorization of a data exchange by that user"
•Nonrepudiate means to accept
•An example of a nonrepudiation measure is the use of electronic signatures to assure the authorship of a record entry in which rules built into the EHR will date and time stamp the entry and then lock the notation or report to prevent future changes to the original information documented in the record
Quality Control Functions for Hybrid Records: What are quality control processes essential for?
Quality control processes are essential for insuring data integrity and availability
In addition to those already discussed, the following are important quality control functions:
1. Quality Control in Record Processing
2. Reconciliation in the Hybrid Record
Quality Control in Record Processing
•The quality control function in the hybrid record should be performed at the time records are processed
•Each page of the health record must be checked prior to document scanning to verify that it belongs to that patient's record
•After the record is scanned, the images are often reviewed to ensure that a high-quality image has been achieved
•If an image is found to be unclear, the document is rescanned after adjustments are made to the computer or scanner.
•Record processing is also monitored to assure that records are processed in a timely manner and meet standards set forth by the healthcare facility
•For example, a healthcare facility may have a standard that all records for discharged patients are scanned and available in the EDMS for completion within 24 hours of discharge
•The HIM professional may monitor the health records processed on a daily basis to determine if this standard is being met
Reconciliation in the Hybrid Record
•Record reconciliation is the process of checking individual data elements, reports, or files against each other to resolve discrepancies in accuracy of data and information
•In paper-based systems, reconciliation usually is incorporated into the chart analysis process
•In a hybrid record system, reconciliation may be even more challenging because data are being captured from a variety of sources and moving across interfaces. •Figure 8.13 provides a comparison of reconciliation quality control tasks across paper-based, hybrid, and electronic health record systems
8.13 Comparison of reconciliation process:
Process: Inpatient visit
Paper systems: Verify that a record exists for each discharge. Verify correct patient type registered (for example, inpatient, short stay, observation status) to ensure accurate billing
Hybrid or Transitional Systems: Same with addition of monitoring canceled admits.
Full Electronic Systems: SAME
8.13 Comparison of reconciliation process:
Process: Emergency department, outpatient, and clinic visits
Paper systems: Verify that record exists for every registration. Verify correct registration of multiple visits in one day according to APC regulations.
Hybrid or Transitional Systems: Same with addition of monitoring canceled admits.
Full Electronic Systems: SAME
Issues and challenges with hybrid records:
•One of the main challenges with the hybrid record is establishing a policy of what comprises the legal health record, discussed later in this chapter
•The policies defining the legal health record must be updated as the paper-based component and functions transition into electronic formats
•The policies must clearly identify what components will be disclosed upon request
Dual work processes and hybrid record:
•Dual work processes often exist with a hybrid record
•The management of the health record may be challenging as paper and electronic work processes coexist
•Health records may still need to be assembled to some degree before scanning and imaging can be done •Additionally, when scanning and imaging are part of the hybrid record process, there is a cost associated with the existence of paper records and the cost of imaging equipment to provide an electronic view of the health record
•Paper records still need to be retrieved from patient care units and then reconciled with discharged patient lists to assure that all health records are received in preparation for the scanning process
"Selling" the transition to the EHR to all health record users:
•Another key issue may be "selling" the transition to the EHR to all health record users
•The HIM professional must be a change agent in the process and recognize that the transition to an electronic health record will be easier for some than others. Not all clinicians embrace the use of technology and some may be reluctant to use the new technology
Check your understanding 8.6
1. Which of the following chart-processing activities is eliminated with an EHR that uses scanned images?
Check your understanding 8.6
2. One of the advantages of an EDMS is that it can:
A. Help manage work tasks
Check your understanding 8.6
3. Which term indicates that a document has been removed from standard view?
Check your understanding 8.6
4. Which term is the process of checking individual data elements, reports, or files against each other to resolve discrepancies?
Check your understanding 8.6
5. Which of the following could be used to determine if someone has the right to view a health record?
A. Photo identification
HIM Functions in an Electronic Environment: An electronic health record (EHR):
•An electronic health record (EHR) is an organization-wide health record that is stored and accessible via the computer
An EHR is comprised of many of the same electronic components used in what other kind of record? Where does an EHR reside?
•The EHR is comprised of many of the same electronic components utilized in the hybrid record, but is a record that resides entirely in electronic format with work processes performed via the computer
The EHR provides for clinical decision support through the availability of what kinds of resources?
•The EHR provides for clinical decision support through the availability of references, interoperability to promote health information exchange (HIE), and standardized terminology that supports data mining for data use
The Healthcare Information and Management Systems Society defines the EHR as (HIMSS 2009):
•A longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports
•The EHR automates and streamlines the clinician's workflow
•The EHR has the ability to generate a complete record of a clinical patient encounter—as well as supporting other care-related activities directly or indirectly via interface—including evidence-based decision support, quality management, and outcomes reporting
What was the result of signing of the American Recovery and Reinvestment Act (ARRA) in February 2009?
The federal government further defined a "qualified" electronic health record as including "patient demographics and clinical health information, such as medical history and problem lists and has the capacity":
1. To provide clinical decision support;
2. To support physician order entry;
3. To capture and query information relevant to healthcare quality; and
4. To exchange electronic health information with and integrate such information from other sources.
With the signing of the American Recovery and Reinvestment Act (ARRA) in February 2009, the EHR has evolved into:
Therefore, the EHR has evolved into more than an imaged record residing within an electronic document management system. Chapter 4 provides a full description of the EHR and its capabilities
Transition Functions to an EHR: The hybrid record as discussed earlier is a transitional health record that exists as the? How is the hybrid record comprised?
•paper-based record evolves to an electronic health record
•Both paper and electronic components comprise the hybrid record
What is the promise of the EHR? What really is EHR? Does it always work? What should be done in addition to transitioning to EHR?
•Streamline information handling and ultimately reduce costs and improve care
•Important to remember that the EHR is really just automation, not a magic bullet
•If a hospital has poor workflow processes, migrating to electronic records will simply automate those poor processes, not solve them. •Therefore, re-engineering manual systems and processes represents a major opportunity for reducing costs, improving service and establishing the correct infrastructure to transition to the automated hospital record
What must the EHR planning process include?
•The planning process must include key clinical and administrative departments that contribute to the health record
What steps must be considered in the planning process to move to a totally electronic environment with communication a key throughout (Reino 2005):
•Defining the facility's legal record
•Standardization of forms and processes
•Development of a forms catalog or inventory
•Barcoding of forms
•Criteria development for hardware, software, and vendors
•Privacy and security procedure establishment
•Training of staff and medical staff
More discussions regarding transition to EHR included in the book:
•A complete discussion of transition to the EHR is provided in Chapter 4.
•Issues related to the planning, design, development, implementation, and maintenance of information systems including vendor selection processes are explained in Chapter 15.
Record Filing and Tracking of EHRs: Traditional record filing; how is the need to file records reduced/eliminated?
•Traditional record filing is a function that is either eliminated or reduced in an electronic health record environment
•As data are increasingly captured and entered into the computer at the point of care, paper documentation is greatly reduced and therefore the need to file the record is either reduced or eliminated
For portions of a record that are stored in an EDMS what may there be awaiting destruction based on the facility's retention policies?
•As discussed earlier, for portions of a record that are stored in an EDMS there may be some storage of paper records awaiting destruction based on the facility's retention policies
What is the traditional tracking of record access and the locations of charts removed from the paper-record system replaced by?
•The traditional tracking of record access and the locations of charts removed from the paper-record system is replaced by the monitoring of access of the electronic health record by the use of an audit trail.
•The function and content of audit trails are discussed in chapter 15
Record Processing of EHRs: Record filing is a function that is eliminated or reduced in what kind of environment? And why?
Record filing is a function that is either eliminated or reduced in an electronic health record environment because data are captured and entered into the computer at the point of care.
In EHR, what happens to the loose report? What does this process ensure?
•In an EHR, the loose report is "indexed." •Indexing is similar to filing in the paper record and ensures that documents are placed in the right location within the right record to allow future retrieval
How is record completion in the electronic health record environment done? How can healthcare professionals access, complete, and authenticate records?
•Record completion in the electronic health record environment is done via the computer. •Healthcare professionals can access, complete, and authenticate records using an electronic in-box, work list, or other tool
How can Management reports related to record completion be generated in EHR? What is the benefit to health records with deficiencies within the EHR system? How does the EHR help facilitate the medical coding and billing process?
•Management reports related to record completion can be generated by the system •Work queues allow the record to be routed to multiple locations within the EHR to allow simultaneous completion of the record by multiple users
•Health records with deficiencies assigned to multiple physicians for completion are completed in a more timely manner in the EHR environment because more than one person can access the record from assigned work queues. •Health records can be routed to the medical coding queues at the same time the records are available for completion in the record completion queues, thus facilitating the medical coding and billing process
As with record filing discussed earlier, the traditional tracking of the locations of charts removed from the paper-record system is replaced by monitoring access to the electronic health record by the use of an audit trail.
Version Control of EHRs: What are some problems created from different document versions? How is this combated?
•Paper-based, hybrid, and electronic health records may have different versions of a document within the health record
•One example where multiple versions could exist is in an electronic health record where there is a medical report that is unsigned and then the physician signs the report
•This represents two versions of the same document, one signed and the other unsigned. •Similarly, when a physician makes changes to a health record or amends it, multiple versions of the document exist
•Each healthcare facility must have policies and procedures for version control stating which versions of the document will be viewable within the health record
•Documents must be "flagged" when an earlier version of a document exists and the date and time of the availability of each version of the document must be clearly documented
Management of Free Text in EHRs, what is it and what are it's difficulties?
•Free-text data is the narrative unstructured data that is the result of a person typing data into a word processing system
•The nature of free text is that it is undefined, unlimited, and unstructured. For these reasons, it is more difficult for a search engine to find, retrieve, and manipulate data than structured text.
How are issues with free text data dealt with? What is an example of a document comprised of free text data? What advantages of manipulation of data that the EHR offers are lost with free text?
•The use of free text should be limited in an electronic health record environment. •Transcribed medical reports are an example of documents comprised of free text data
•Many of the advantages of manipulation of data that the EHR offers are lost when the health record is comprised of large amounts of unstructured data.
What strategies can be used to provide structure for data capture?
•Pointing and clicking to select structured text is one option that may be utilized by users of the electronic health record
•The use of voice recognition software also provides for structured data capture
•Some EHR users prefer to copy and paste text from existing documents in order to speed up the documentation process
•Allowing this practice should be assessed carefully
•Similar to documentation in paper-based records, individuals who document in the EHR must be held accountable for their entries
What risks are inherent in the use of copy functionality?
•These tools, if used inappropriately, may undermine the clinical decision-making process. •For example, copying information into the wrong patient health record could adversely impact patient care
•And overuse of disk space, from redundant copied information, can affect overall system response time
Specific risks to documentation integrity of using copy functionality include (Gelzer et al. 2008, 6):
1. Inaccurate or outdated information that may adversely impact patient care
2. Inability to identify the author or what they thought
3. Inability to identify when the documentation was created
4. Inability to accurately support or defend E/M codes for professional or technical billing notes
5. Propagation of false information
6. Internally inconsistent progress notes
What should a health care facility do because of the risks to integrity of using copy and past functionality?
Because of these issues, the healthcare facility should have in place policies and procedures related to the copying and pasting of free text in the electronic health record.
Management and Integration of Digital Dictation, Transcription, and Voice Recognition: what is the most common method to capture dictation in the EHR?
•The most common method to capture dictation in the EHR is the use of digital dictation
•With digital dictation, the physician dictates a medical report and the transcriptionist transcribes the dictation into a structured medical report
•The transcribed reports are electronically transmitted to the EHR
•The EDMS attaches an auto-signature deficiency and the transcribed report is then electronically routed to a physician work queue for signature.
What is another technology method used to capture dictated reports in the EHR? As this evolves, what is emphasized?
•Voice recognition technology is another method used to capture dictated reports in the EHR
•With voice recognition technology the computer software captures the dictation and converts the dictation to text
•Backend voice recognition software or voice recognition at the point of transcription is most commonly used for routine transcription of reports
•As the practice of medical transcription evolves and voice recognition software is utilized, emphasis is placed on medical language editing, data quality control, and text/document management
The HIM professional must establish a monitoring system and implement productivity standards in order to do what?
•The HIM professional must establish a monitoring system and implement productivity standards to access the accurate capture of dictation and transmission to the EHR
•The implementation of quality and productivity standards reduces turnaround time and improves the quality of information for workflow processes and regional health data exchange
Reconciliation Processes for EHRs: what do the EHR's require that the HIM professional verify?
•As with the reconciliation process for the paper-based and hybrid records, electronic health records require that the HIM professional verify that there is an electronic health record present in the system for every discharged patient and verification of reports
•These processes are expanded in a fully electronic health record system. Figure 8.13 (p. 425) provides a comparison of these processes for the paper-based, hybrid, and electronic systems.
Managing Other Electronic Documentation: New information technologies are producing what that was unknown even a decade ago? Policies and procedures should be in place for the management of all electronic information that is generated about patients in healthcare organizations, regardless of?
•New information technologies are producing patient health information and documentation that was unknown even a decade ago
•For example, e-mail and voice mail records and audio and video data could be part of an EHR
•Consequently, policies and procedures should be in place for the management of all electronic information that is generated about patients in healthcare organizations, regardless of the record type and medium (AHIMA Workgroup on Electronic Health Records Management 2004)
Media and associated issues: Email
•In today's healthcare setting, e-mail is often used as a main form of communication
•Often e-mail is used to communicate patient-specific information
•The organization should have in place policies and procedures that address the creation, storage, and maintenance of e-mail messages. •When patient-identifying information is communicated via e-mail, an e-mail management system should be used for inclusion of the data in the electronic health record
•An e-mail management system should consist of a centralized archive capable of enforcing archiving policies
•The e-mail management system should also allow e-mails to be classified by type (that is, patient e-mail) and apply rules for archiving, retention, and integration of e-mails into the electronic health record
•The management system can also be set up to automatically encrypt patient e-mails to provide a level of security
Media and associated issues: Voice Mail (what should happen to the msgs?)
•Voice mail containing patient specific information regarding the patient condition and/or treatment should also be included in the electronic record
•In paper-based systems this is usually handled by transcribed notes placed into the medical record
•In an EHR environment, voice mail messages and telephone conversations should be documented
•The messages should include provider and patient identification, date and time of actual conversation or message, and the date and time of entry into the EHR. Each of these messages should also be indexed so that they can be searched, retrieved, routed, or purged
Handling Materials from Other Facilities: How is it handled?
•Materials in the form of hardcopy records, diagnostic images, cine films, or compact discs may be received from other facilities that have provided an individual with care
•In paper-based systems, the disposition of hardcopy materials is handled according to the organization's written policies and procedures
•Frequently the material is incorporated into the medical record
•In fully electronic systems hardcopy materials are scanned into the EHR and diagnostic images, film, and CDs become part of the EHR
Search, Retrieval, and Manipulation Functions of EHRs:
•In an electronic record environment, large volumes of data are entered into the EHR in structured and unstructured formats.
•The goal of the electronic health record system is to enable retrieval of information to assist healthcare professionals in providing quality patient care and reporting patient outcomes. •The higher degree of structure in the data entered into the EHR provides for the retrieval of meaningful data and ease of manipulation of that data.
Search, Retrieval, and Manipulation Functions of EHRs: Data mining
•Data mining is the process of analyzing data from different perspectives and summarizing it into useful information
•Data mining software is one of a number of analytical tools for analyzing large amounts of data
•It allows users to analyze data from many different dimensions, categorize it, and summarize the relationships identified. •Technically, data mining is the process of finding correlations or patterns among dozens of fields in large relational databases
Access Control for EHRs: main advantages / what must organizations have in place to ensure safety of data?
•One of the main advantages of the EHR is that the health record can be viewed by multiple users and from multiple locations and at anytime
•This advantage also has the potential for abuse and security risks
•Therefore, organizations must have in place appropriate security access control measures to ensure the safety of data. Chapter 15 provides a full discussion of the methods summarized below
The foundation on which access control is based includes:
identification, authentication, and authorization
The basic building block of access control is identification of an individual. Usually identification is performed through the username or user number
The second element of access control is authentication. What are the 3 diff types of information that can be authenticated? What is the most common method?
Authentication is the act of verifying a claim of identity
•There are three different types of information that can be used for authentication: something you know, something you have, or something you are
•The most common method of authentication is the use of usernames and passwords
•As discussed earlier, access control is strengthened by the use of "strong" passwords that include numbers and upper- and lowercase letters and that are not easily identifiable names or numbers.
How might a higher level of authentication be accomplished?
•A higher level of authentication may also be accomplished with the use of biometrics identification
•Biometrics are individual specific identifiers such as fingerprints, retinal scans, and voice recognition that uniquely identifies the person. •Biometric identifiers are sometimes found on desktop computers, laptops, and other access devices
How can access cards also be used to authenticate the user's right to access the record system?
•Access cards are often used in combination with passwords or personal identification numbers (PINs) as a method of authenticating the person's identity
The third element of access control is authorization:
•Authorization is a right or permission given to an individual to use a computer resource or to use specific applications and access specific data
•It is also a set of actions that gives permission to an individual to perform specific functions such as read, write, or execute tasks
How is authorization for using a computer system usually addressed?
•Authorization for using a computer system is usually addressed through identification and authentication described previously
•Authorization to use specific applications (that is, order entry, coding, and registration) and specific data would be different among individuals in an organization
•For example, employees in the admitting and registration department would not be given the same authorization to use computers, programs, and data as nursing care employees
How is authorization usually managed? What may it be based on?
•Usually authorization is managed through special authorization software that uses various criteria to determine if an individual has authorization for access, sometimes referred to as an access control matrix
•For example, authorization may be based on not only the individual's identity but also the individual's role (called role-based authorization), physical location of the resource (that is, access to only certain computers), and time of day
Nonrepudiation: definition and example
•As stated earlier, nonrepudiation measures "limit an EHR's user's ability to deny (repudiate) the origination, receipt, or authorization of a data exchange by that user" (Dougherty 2008). Nonrepudiate means to accept
•An example of a nonrepudiation measure in the electronic environment is the use of electronic signatures.
Electronic signatures assure the authorship of a record entry by using? What does the use of repudiation reduce the likelihood of?
•Electronic signatures assure the authorship of a record entry by using rules built into the EHR that date and time stamp the entry and then lock the notation or report to prevent future changes to the original information documented in the record
•The use of repudiation reduces the likelihood that an individual can deny making an entry or the timing of an entry
Handling Amendments and Corrections in EHRs: As stated earlier, health records may occasionally require that entries be amended, corrected, or deleted. What must be in place regardless of the media used?
•Regardless of the media used to store the health record, policies must be in place to assure the integrity of the information contained in the health record as a business record, as a legal health record, and as a patient care communication tool
•The healthcare facility must have written policies that specify who, when, and how amendments, corrections, and deletions may be made to a health record
•In the electronic health record the same premise applies to making changes to a health record as it does to a paper-based record
What policies specifically must be addressed with the functionality of the EHR and increased accessibility of the health record?
However, with the functionality of the EHR and increased accessibility of the health record, policies must specifically address who may make changes to the health record, within in what time frame corrections can be made, and how these changes will be documented.
What does "functionality" refer to in the EHR? How does the functionality of the EHR varies depending on the system used?
•Functionality refers to features in the EHR that allow the user to maintain different versions of a document, track changes made to a document, lock a document from changes, and create user profiles that limit who may edit entries and so forth
Who has the ability to "unlock" a record? How should this be tracked?
•The ability to "unlock" a record should be given to only a few individuals and typically this would be the health information manager
•The HIM professional must track changes to the health record and assure appropriate follow-up in any source systems or other data repositories
•Source systems refer to other computer systems that feed information into the EHR, which would also need to be corrected according to policy when corrections are made in the EHR
Examples of policies that may be written regarding amending, correction, or deleting health record entries are (Hall et al. 2009):
•After a document or entry in a health record has a final signature on it, the only way to correct it is to add an addendum to the record. The addendum must have a separate signature, date, and time from the original entry.
•The original version of the document in a corrected health record must be maintained. The version should be clearly indicated on the document. For example, reports should indicate, "final copy," "preliminary copy," or "final copy with corrections."
•A health record should be locked from editing once the final signature has been applied.
•The appearance of information added to the record to amend or correct it should be different than the original entry (that is, it may be a different color, italic, or bolded)
Purge and Destruction of EHRs
•Retention of electronic health records is similar to health records in a paper-based and hybrid environments
•The healthcare facility must consider state and federal regulations, statutes of limitation, research and educational needs, and patient care needs
•Many healthcare facilities maintain health records indefinitely or for a period that exceeds the statutes of limitations.
Retention periods for records vary from:
•Retention periods for records vary from state to state and by patient populations
•For example, retention requirements or guidelines are typically longer for the records of minors than adult health records
•Regardless of the media used to store records, at some point the healthcare facility will need to address when and how health records will be purged and/or destroyed.
•In the EHR environment, the facility may choose to maintain either the entire record indefinitely or to "selectively" purge health information for destruction
•With selective destruction, the healthcare facility may choose to purge specific information from the health record after the retention period has expired
•For example, the facility may have a policy where nursing graphic reports may be purged from the system, but physician documentation is maintained.
What needs to be done with an EHR facilities computer equipment and computer storage media when broken or obsolete?
•In the EHR environment the facility must also have a policy for destruction of computer equipment and computer storage media when it is no longer functioning properly or has become obsolete
•The EHR equipment may have patient health information stored on it
•Policies must specifically address how health information will be removed from servers, workstations, laptop computers, and other storage media once this hardware will no longer be used for the EHR
•The removal of information from computer equipment requires more than simply deleting files
•The healthcare facility must run utility software to remove data or neutralize the data by applying magnetic erasers
•If these methods of destroying the data are not possible, the hard drive must be removed from the computer and physically destroyed. •Compact disks used for storing data may be destroyed by shredding or pulverizing and then disposal
Quality Control Functions for EHRs: when does data quality begin?
•Data quality begins at the point of creation (Johns 2002)
•In the electronic environment, managing data input through good design of end-user interfaces increases the probability of quality data
As noted earlier in this chapter, in the EHR data are captured by:
•Data entered directly into the computer at the point of care
•Paper documents are scanned and imaged
•Other computer systems are interfaced with the EHR (for example, laboratory results, radiology)
•Transcribed reports are electronically transmitted to the EHR
Input masks, lookup values, and validation rules can provide for what? What do these features specifically include?
•Input masks, lookup values, and validation rules can provide for quality discrete, structured data that are more easily manipulated and analyzed
•Specifically, these features include drop-down menus, built in data values, and checkboxes •Although these features provide for consistent entry of data for routine data, they are limited in allowing the practitioner to document complex cases
More complex cases may require the physician to use free text to adequately document a patient's condition. What are quality issues?
•Free text is unstructured data and limits the facility's ability to report data
•Dictation templates may be utilized to structure or prompt the physician for needed documentation, thus improving the quality of dictated reports
•Additionally, illegibility is also a quality issue when scanned images are used in the EHR •Therefore, the decision as to how much structured data may be required and when to allow unstructured data should be collaboratively decided by all stakeholders
What is another step to managing the quality data in the EHR?
•is to monitor errors that occur
•Most EHRs generate error reports or utilize error queues when there are mismatches between the EHR and the other computer systems that feed information into the EHR •When errors are identified, there must be a process in place for correction
what should the screen design be evaluated for when selecting an EHR?
•When selecting an EHR, the screen design should be evaluated for features that will contribute to the capturing of quality health data
•Similar to good forms design in the paper-based environment, well-designed EHR screens will provide ease of use, which in turn helps to provide quality data
•Screen design or system features that should be evaluated when assessing a computer system are (Williams 2006):
•Clear navigational buttons that direct the user to the next step in the documentation process and buttons to view the previous screen are imperative to assuring the user can use the system with ease
•Clear labeling of buttons and data fields
•Limiting the use of abbreviations on buttons and data fields
•Consistent location on the screen of navigation buttons
•Built-in alerts to notify the user of possible errors
•Availability of references at the appropriate data field
•Prompt for more information where appropriate
•Checks for warning signs or errors
Additional considerations that should be followed when developing user views or screens include the following:
1. Navigation design
2. Input design
3. Data validation
4. Output design
•All controls should be clear and placed in an intuitive location on the screen.
•Use neutral colors and limit highlighting, flashing, and so forth to reduce eye fatigue.
•Limit choices and label commands.
•Provide "undo" buttons to make mistakes easy to override
•Use consistent grammar and terminology.
•Provide a confirmation message for any critical function (such as deleting a file)
•Simplify data collection
•Sequence data input to follow workflow.
•Provide a title for each screen.
•Minimize keystrokes by using pop-up menus
•Use text boxes to enter text
•Use a selection box to allow the user to select a value from a predefined list:
—Check boxes (used for multiple selections)
—Radio buttons (used for single selections)
—On-screen list boxes
•Drop-down list boxes
•Perform a completeness check to ensure that all required data have been entered.
•Perform a format check to ensure that data are the right type (numeric, alphabetic, and so on).
•Perform a range check to ensure that numeric data are in the correct range.
•Perform a consistency check to ensure that combinations of data are correct.
•Perform a database check to compare data against a database or file to ensure data are correct as entered
•Minimize the number of "clicks" needed to reach data or a specific screen.
•Combine data into a single organized menu to eliminate layers of screens.
What should the system also do so that the EHR user cannot proceed to the next screen without completing required information?
They system should also mark required data fields so that the EHR user cannot proceed to the next screen without completing required information
As discussed in chapter 4, the quality of patient care is also improved through a:
•Well-designed user interface and decision support features
•For example, quality patient care is enhanced when there are built-in alerts that check for possible medication interactions and allergy information when medication orders are documented
•The availability of references allows the physician to easily look up information, without having to rely on memory in prescribing medications or considering a course of treatment
Check your understanding 8.7:
1. Version control of documents in the EHR requires:
B. Policies and procedures to control which version(s) is displayed
Check your understanding 8.7:
2. Which of the following is a risk of copying and pasting?
B. System not recording who entered the data
Check your understanding 8.7:
3. When records from other facilities are used in clinical decision making, how is this documented in the EHR?
B. They are scanned and filed in the EHR
Check your understanding 8.7:
5. How are amendments handled in the EHR?
D. The amendment must have a separate signature, date, and time.
Check your understanding 8.7:
Instructions: Indicate whether the following statements are true or false (T or F).
6. __T__ EHR data are captured by scanning and direct entry
7. __F__ Data validation includes an undo button.
8. _T___ Policies should address how the patient information will be removed from computers at the end of their useful life.
9. __T__ Data quality begins at the point of creation.
10. __F__ Authorization is identifying a patient through the use of a user name
The conversion of verbal medical reports dictated by healthcare providers into written form for inclusion in patients' health records
What do physicians and clinicians use for dictating reports?
•Physicians and other clinicians use automated computer medical dictation (sometimes referred to as voice capture) systems for dictating reports
Medical reports commonly dictated (recorded) include:
•The clinical history, physical examination, consultation report, operative report, discharge summary, pathology reports, and radiology reports
•The dictation is stored in either tape or disk format in the dictation system
•Medical transcriptionists retrieve the dictated reports and type them using word-processing systems
•The final typed report can be printed in paper format or stored electronically in an EHR
Management of Medical Transcription: historically, the HIM department provided medical transcription services. What is done more recently?
•More recently, however, these services have been subsumed by other departments or have been centralized in a separate department
•In other cases, the entire medical transcription function has been outsourced (contracted out to a vendor)
•In many instances, outsourcing part or all of the transcription function can provide substantial benefits, including cost reductions and relief from staffing issues that sometimes result in transcription delays
•More recently, large in-house transcription areas and outsourcing agencies have begun using speech recognition technology to transcribe recorded dictation
•Speech recognition technology may be applied on the front end (at the point of dictation) or back end (after dictation has taken place)
•It enables the dictator's digitized voice recording to be processed through a computer that converts it into text
•Templates or standardized documents can be used to reduce the number of errors
What will the use of speech recognition technology have an impact on?
The use of speech recognition technology will have an impact on the role of the medical transcriptionist, which is expected to become that of a medical language editor
Quality Control: Like the other HIM functions discussed in this chapter, it is important to monitor the quality and timeliness of medical transcription. The following are examples of the quality of the medical transcription service that can be monitored:
1. To monitor transcription accuracy, a sample of the transcriptionists' reports can be checked for wrong terms, misspelled words, incorrect format, and/or grammatical errors
•The number of errors found is noted, and an error or accuracy rate is determined and compared against an established standard
2. Transcription turnaround time also can also be monitored to determine whether reports are being transcribed within the expected time frame set in a standard
•Most dictation/transcription computer management systems track the date and time reports are dictated and transcribed
•A report indicating dictation and transcription time and date can be used to determine turnaround time
Release of Information (ROI) Protecting the security and privacy of patient information is one of the healthcare institution's top priorities. The HIM dept usually has responsibility for determining what in terms of release of information?
•The HIM department usually has responsibility for determining appropriate access to and release of information from patient health records
•For example, release of information (ROI) may take the form of a patient's request to mail copies of his or her records to a healthcare provider
The management of the release of information function includes the following steps: Step 1
1. Enter the request in the ROI database: •Generally, information such as patient name, date of birth, health record number, name of requester, address of requester, telephone number of requester, purpose of the request, and specific health record information requested is entered in the computer
•Figure 8.14 is an example of the computer screens used for entering ROI data
The management of the release of information function includes the following steps: Step 2
2. Validity of the authorization is determined: •The HIM professional will compare the authorization form signed by the patient with the facility's requirements for authorization to determine the validity of the authorization form. •The facility's requirements are based on federal and state regulations
•Certain types of information such as substance-abuse treatment records, behavioral records, and HIV records require specific components be included in the authorization form per state (varies per state) and federal regulations
•If the authorization is determined to be invalid, the request is returned to the requester with an explanation as to why the request has been returned
•If the request is valid, the HIM professional proceeds to the next step
The management of the release of information function includes the following steps: Step 3
3. Verify the patient's identity of record requested: The HIM professional must first verify that the patient has been a patient at the facility
•Verification is done by comparing the information on the authorization with information in the master patient index
•The patient's name, date of birth, Social Security number, address, and phone number are used to verify the identity of the patient whose record is requested
•The patient's signature in the health record is compared with the patient's signature on the authorization for release of information form
The management of the release of information function includes the following steps: Step 4
4. Process the request: The record is retrieved and the only the information authorized for the release is copied and released
Due to what does the HIM department personnel have to know what info needs to be included on the authorization for it to be considered valid?
Because federal regulations such as HIPAA and state laws govern the release of health record information, HIM department personnel must know what information needs to be included on the authorization for it to be considered valid.
Valid or invalid authorization process
•If the written request or authorization is valid, the specific information is copied and sent
•If the authorization is invalid, the problem with the authorization is noted in the computer and the request is returned to the sender
•To comply with HIPAA standards, a healthcare facility must maintain a record that accounts for all disclosures from the health record
ROI in a subpoena for legal case:
•In another case, ROI may take the form of a response to a subpoena duces tecum in a legal case
•(A subpoena duces tecum is a judicial request for certain information or evidence. Refer to chapter 14 for further information on subpoenas.)
•In this instance, the HIM department verifies that the subpoena is valid and that the requested information can be released to the court in compliance with state or federal law or regulations
•In such instances, a representative from the HIM department may appear in person in court or at a deposition and give sworn testimony as to the health record's authenticity
What has been a result of the ROI function growing extensively in the past decade?
•The ROI function has grown immensely in the past decade, in part due to the HIPAA privacy standards
•As a result, some HIM departments outsource this function to companies that specialize in release of medical information
•Even though it has outsourced the function, the HIM department is ultimately responsible for ensuring that proper practices are followed and that all laws and regulations are adhered to
ROI Quality Control: The HIM department receives a high volume of requests and must prioritize the processing of release of information.
•Continuity of care requests are processed before other types of requests
•Standards for turnaround time for requests are established by the department
•With standards for turnaround times established, the average turnaround times for release of information may be tracked and delays in responding to requests for information addressed
The following is one of two examples illustrating how the timeliness and quality of the release of information can be monitored.
1. ROI Turnaround Time Monitoring
•The turnaround time for the ROI function is monitored
•The date a request is received and the date the record copies are sent are entered into a computer database
•This information can be used to generate a report that will determine whether the records are being sent in a timely manner
•The accuracy of the ROI function can be monitored by checking a sample of authorization forms that have been sent or that are ready to be sent to verify the validity of the authorization and to ensure compliance with federal and state regulations
•The error rate or accuracy rate can be determined and compared against a set standard
The following is one of two examples illustrating how the timeliness and quality of the release of information can be monitored.
2. Productivity and Backlog Management
•Productivity standards must be established in order to meet the expected turnaround time for the various types of requests
•"While productivity information may be collected manually, electronic systems offer more tools for data manipulation and can provide individual production statistics, departmental request volumes, and information regarding request turnaround times
•Timely fulfillment of requests that ensure continuity of care aligns with the overall mission of most healthcare organizations
•Thus these types of requests frequently take precedence over other categories of requestors •Monitoring the volume of backlog requests with the available resources and making appropriate staffing adjustments ensures the patient's needs are being met" (Bock et al. 2008).
•When the volume of requests reaches beyond the workload capacity of staff meeting productivity and quality standards, the facility may decide to contract with a release of information service to process the backlog
Legal Health Record:
•Regardless of the media used to store the health record, the legal health record must be clearly defined by each facility
•The legal health record refers to the health record that is maintained as the business record and is the health record that may be disclosed to authorized uses and for evidentiary purposes
•Healthcare facilities must have a policy that clearly identifies the legal health record
Figure 8.15 is an example of a legal health record policy from the AHIMA EHR Practice Council (2007). As noted in the policy template in figure 8.15:
•"The determining factor in whether a document is considered part of the legal health record is not where the information resides or its format, but rather how the information is used and whether it is reasonable to expect the information to be routinely released when a request for a complete health record is received."
As the healthcare facility transitions to the EHR, consideration must be given to:
•All media (for example, paper, CD, video, images, films, reference materials, downtime documents) and documentation sources
•Many of the EHR quality management components that assure the integrity of the data contained with the health record are key to defining the health record, including version control, authentication, lockdown procedures, and amendment and correction policies. Chapter 14 provides additional discussion about the legal health record
Figure 8.15. Sample legal health record policy template
Policy Name: The Health Record for Legal and Business Purposes
Departments Affected: HIM, Information Systems, Legal Services, [any additional departments affected]
Purpose: This policy identifies the health record of [organization] for business and legal purposes and to ensure that the integrity of the health record is maintained so that it can support business and legal needs.
Scope: This policy applies to all uses and disclosures of the health record for administrative, business, or evidentiary purposes. It encompasses records that may be kept in a variety of media including, but not limited to, electronic, paper, digital images, video, and audio. It excludes those health records not normally made and kept in the regular course of the business of [organization]
Figure 8.15. Sample legal health record policy template (cont.)
It is the responsibility of [the health records manager or other designated position] to:
•Work in conjunction with information services, legal services, and [other stakeholders] to create and maintain a matrix or other document that tracks the source, location, and media of each component of the health record. [Reference an addendum or other source where the health record information is found.]
•Identify any content that may be used in decision making and care of the patient that may be external to the organization (outside records and reports, PHRs, e-mail, etc.) that is not included as part of the legal record because it was not made or kept in the regular course of business
•Develop, coordinate, and administer a plan that manages all information content, regardless of location or form that comprises the legal health record of [organization]
•Develop, coordinate, and administer the process of disclosure of health information.
•Devise and administer a health record retention schedule that complies with applicable regulatory and business needs
Figure 8.15. Sample legal health record policy template (cont.)
Note: The determining factor in whether a document is considered part of the legal health record is not where the information resides or its format, but rather how the information is used and whether it is reasonable to expect the information to be routinely released when a request for a complete health record is received. The legal health record excludes health records that are not official business records of a healthcare provider. Organizations should seek legal counsel when deciding what constitutes the organization's legal health record.
Policy: It is the policy of [organization] to create and maintain health records that, in addition to their primary intended purpose of clinical and patient care use, will also serve the business and legal needs of [organization].
It is the policy of [organization] to maintain health records that will not be compromised and will support the business and legal needs of [organization].
Figure 8.15. Sample legal health record policy template (cont.)
It is the responsibility of the information services department [or other appropriate department(s)] to:
•Ensure appropriate access to information systems containing components of the health record
•Execute the archiving and retention schedule pursuant to the established retention schedule.
[Additional responsibilities for other individuals or departments]
Tracking and Reporting of Disclosures: In addition to the tracking of disclosures traditionally maintained in the release of information database in which requests for information are entered upon receipt of an authorization to release information, HIPAA requires?
•That healthcare facilities maintain an account of each required disclosure type of protected health information (PHI)
•The following disclosures must be accounted for (Stuard 2003):
-Government mandated reporting
-Disclosures by business associates that are not for treatment, payment, and healthcare operations
What must a facility be able to provide upon request?
•The facility must be able to provide upon request
The date, name of person receiving the information, the address of the recipient, a description of the PHI disclosed, and a statement of the purpose of the disclosure (Stuard 2003)
These types of disclosures may reach beyond the requests and disclosures that are under the auspices of the HIM department. Therefore:
•There must be an organization-wide policy on how compliance with the accounting for disclosure regulation of HIPAA will be accomplished
•Examples of departments that are involved with disclosures that fall under the realms of the HIPAA accounting of disclosures regulations might be cancer and trauma registries, institutional review boards, social work departments, and so forth
•The enactment of the American Recovery and Reinvestment Act (ARRA) changes HIPAA requirements. Additional information about HIPAA and reporting disclosures is covered in chapter 14
•Clinical coding is another important function usually performed by the HIM department. (The specifics of clinical coding are described in chapter 6.)
•Using a classification or nomenclature system such as ICD-9-CM and/or CPT, clinical coding is a method for categorizing diagnoses and procedures. (Adoption of a new coding system called ICD-10-CM and ICD-10-PCS is planned to replace ICD-9-CM in the future.)
•This categorization is used subsequently for billing and payment purposes as well as for research and clinical quality performance reviews
The clinical coding function includes:
•The clinical coding function includes the processes of abstracting and assigning ICD-9-CM and/or CPT codes to an encounter or hospital stay
•The coding professional reviews the health record and enters specific data from it into a computer database
•The process of extracting data from the health record and entering them into a computer database is called abstracting
•Figure 8.16 is an example, but not an exhaustive list, of data that may be abstracted and entered into the computer database
Figure 8.16. Examples of abstracted data fields
Transfer from a hospital
Transfer from a skill nursing facility
Transfer from another healthcare facility
Information not available
Psychiatric and alcohol
The data items included in figure 8.16 are only a partial listing of data abstracted from the health record. A hospital may abstract more than 200 data items from each record. In addition to abstracting, the coding professional also identifies:
•The diagnoses and procedures documented in the health record
•He or she assigns ICD-9-CM (or ICD-10-CM) codes to the diagnoses and procedures and CPT codes (if applicable) to procedures documented in the record
•The coding function may be done manually by finding the correct codes in a coding book or done by using a computer program called an encoder.
•Encoders are software programs that help guide the coder through the various coding conventions and rules to arrive at a correct diagnosis, procedural, or service code (figure 8.17)
•Other programs that are usually part of an encoding system are called DRG and APC groupers for acute care hospitals. DRG groupers are software programs that help coders determine the appropriate diagnosis-related group (DRG) assignment based on the logic of the system for hospital inpatients
•APC groupers are software programs that help coders determine the appropriate ambulatory payment classification for an outpatient encounter
In today's environment, codes for diagnoses, procedures, and services are usually entered:
•Directly into a computer system along with pertinent patient information and other demographics
•Data abstracted and the clinical code(s) assigned to a health record make it possible to create automated disease, operation, and physician indexes (discussed later in this chapter)
•Such indexes are essential in order to retrieve data or specific health records to conduct research or clinical quality performance studies
Like quantitative analysis, clinical coding can be either:
•Concurrent or retrospective
•In some acute care and long-term care facilities, the coding of diagnoses, procedures, and services occurs during the patient's hospital stay
•In this method, the HIM professional goes to the nursing unit daily or periodically reviews the health record and assigns appropriate diagnosis, procedural, and service codes
•In the retrospective process, the health record is coded after patient discharge
•Coding usually occurs after the health record has been assembled and analyzed for completeness
Quality Control in Clinical Coding: Like the other HIM functions discussed in this chapter, it is important to monitor the medical coding. Following is an example of how the quality of the medical coding service can be monitored:
•Monitor the clinical coding function for accuracy, a sample of records for each clinical coder can be reviewed to verify that coding rules and principles are being applied
•Criteria such as correct code assignment, missing codes, extra codes, and sequencing of codes can be established
•Any errors found should be noted, and an error or accuracy rate can be calculated to determine whether the quality standard is being met
Revenue Cycle Management
•Revenue cycle management is a system that involves several processes working together to ensure that the healthcare facility is properly reimbursed for the services provided
•Major functions of revenue cycle management include: admitting/access management, case management, charge capture, HIM, patient financial services/business office, finance, compliance, and information technology (Amatayakul 2005)
Other HIM department functions:
•Research, statistical reporting, cancer registries, trauma registries, and birth certificate functions require data contained in the health record
•Therefore, the HIM department often manages these functions.
Data Reporting and Interpretation: Many HIM departments include a research division.
•The type of research assistance provided to clinicians, medical staff committees, and clinical administrative decision support varies from organization to organization
•Some HIM research sections are responsible for identifying candidate health records for research projects that clinicians are conducting
•An example might be that of a physician doing a study on patients diagnosed with hypertension and diabetes who are being given a specific type of medication
•In this case, the research section would use disease and procedure indexes to identify and retrieve the appropriate health records
•In some cases, the HIM research professionals might not only identify and retrieve the health records, but also actually review the selected records and abstract or collect data from them for the physician researchers.
In addition to research functions, many HIM departments are responsible for collecting and calculating various statistics about the operation of the healthcare facility: what ratios are among these?
•Among these are ratios and percentages such as the percentage of occupancy, death and autopsy rates, and hospital census reports •Where the institution has integrated computer information systems, many of these types of statistics are generated automatically
•This is particularly the case with daily hospital census reports and percentage of occupancy •However, data entry and other errors often produce incorrect results, so it is still usually the function of the HIM department to verify the accuracy of many of the statistics calculated about institutional operations
Maintenance of Indexes and Registries
•HIM departments often also have responsibility for maintaining indexes and registries
•An index is a guide that serves as a pointer or indicator to locate something
•For example, the index at the back of this book lists key terms
•The page number(s) by each term indicates where in the book the reader can find information about that particular term
•Following is a brief overview of indexes and registries
Disease and Operation Indexes: Compiling and maintaining disease and operation indexes has always been an important function of the HIM department
•In these indexes, diagnoses and operative codes, like those used in a classification system such as ICD-9-CM, are used as guides or pointers to the health records of patients who have had a specific disease or operation •Disease and operation indexes are essential for locating health records to conduct quality improvement and research studies, as well as for monitoring quality of care
The minimal amount of data required for a disease or operation index usually includes:
•The principal diagnosis and relevant secondary diagnoses
•Patient's health record number
•Patient's gender, age, and race
•Attending physician's code or name
•The hospital service
•The end result of hospitalization
•Dates of encounter (including admission and discharge for inpatients)
Given this type of information, the index can be used as:
•A guide for retrieving health records for research or other studies
•For example, if the clinical quality committee wanted to see the health records for all male patients who had been diagnosed with myocardial infarction, were 50 years old or less, had been treated in the past 6 months, and had been discharged alive, the records could be easily identified and subsequently retrieved using the information in the index.
Today, most indexes are automated except:
•Except for those in very, very small facilities •The automated disease and operation index usually is accomplished by generating standard or ad hoc reports of data already existing in the computer
•Ad hoc reporting capabilities enable the user to select the field items he or she wants in the reports
•Standard reports are preexisting reports that have been programmed into the computer to include predefined data fields.
In many institutions, much of the information needed for disease and operation indexes is entered into the computer system concurrently with:
•The diagnosis coding process
•In other facilities, the data may be entered during a separate function of abstracting data from the health record and entering them into the computer system
•In some cases, pertinent demographic patient information is exchanged from the automated R-ADT system and passed to the coding system •This type of data exchange helps to reduce work and data-entry redundancy and to increase data integrity and consistency
In a manual indexing system, special index cards are used to record the pertinent data:
•The cards are preprinted with the pertinent categories of data to be collected
•Usually, several entries (such as encounters) can be made on one card
•There are various methods for filing disease and operation index cards
•One common method is to enter encounters sequentially by date of discharge starting at the beginning of each year
•Each card is then numbered sequentially beginning with the numeral one and filed by year
A manual indexing system description illustrates:
•This description illustrates how difficult it is to compile, maintain, and retrieve data from a manual index
•As with any manual system, opportunities abound for data-entry error
•Cross-indexing of diseases and operations is impossible without an enormous amount of data redundancy, and retrieval is very time-consuming
•Like the disease and operation indexes, the physician index is a guide to identifying medical cases associated with a specific physician
•Often the information gathered for disease and operation indexes is sufficient for the physician index
•Essentially, the data required in such an index include the physician's name or code; the health record number, diagnosis, operations, and disposition of the patients the physician treated; the dates of the patient's admission and discharge; and the patient's gender and age
•In addition, certain other patient demographic information may be useful.
•A registry is a chronological listing of data, or register. With regard to HIM functions, traditional registries include the patient admission and discharge register, operating room register, and birth and death registers. •Most information collected today for registries is a byproduct of other automated systems
•A more complete discussion of registries is provided in chapter 9
Cancer and Trauma Registries:
•The HIM department also may manage the cancer and trauma registry functions
•Cancer registries use information from patient records to collect data for the study and treatment of cancer
•Likewise, trauma registries use information from the patient record to collect data for the study and treatment of trauma patients
•Both registries maintain large computer databases to store patient data
Birth Certificates and the HIM department:
•Sometimes the HIM department is responsible for submitting an accurate birth certificate to the health department
•A birth certificate must be completed for each newborn before the infant is discharged from the hospital
•Information is gathered from the mother's and baby's medical record for completion of the birth certificate
•Chapter 10 discusses birth certificate requirements and functions in additional detail
HIM Interdepartmental Relationships
•Performing HIM functions efficiently and effectively involves the interface and cooperation with many clinical and administrative departments in the organization.
Good working relationships and communication among all of these departments are essential. These interdepartmental relationships are described:
•As discussed earlier in the section on the MPI, typically, the first point of data collection in any healthcare organization is patient registration. •During the registration process, the patient provides the registration or admitting clerk with personal information
•The patient's information is needed for the identification, treatment, and payment of healthcare services
•For example, the patient provides demographic information such as name, address, telephone number, and emergency contact information
•He or she also provides information about how payment should be handled (for example, insurance company name and insurance group number)
For inpatient or same-day surgery admissions, what other information is provided by the patient's attending physician and integrated into the registration data collection and processing:
•Provisional diagnosis, and
•Planned treatment, is provided by the patient's attending physician and integrated into the registration data collection and processing
•For a laboratory or radiology referral, an order for a test or treatment must be accompanied by a tentative diagnosis or a reason for the order. •The patient registration function essentially begins the process of documenting the patient's care and treatment
Where does the health record begin?
•Patient registration is the area where the health record begins
•Additionally, it is the area where the health record number is assigned
•The accuracy of the information entered into the computer by the patient registration area has a significant impact on the HIM department, patient care areas, and billing department
Data quality always begins where? What happens in the case of incorrect data and errors?
•At the source of the data
•When data are recorded or obtained incorrectly at the start of the process, the errors follow the data throughout their use in the healthcare organization's business and patient care processes
•For example, an error made in entering a patient's health insurance number in the computer system will likely cause serious problems for the billing office
•An error made in recording a patient's provisional diagnosis may have adverse effects on the delivery of patient care
•An error in assigning a new health record number to a patient who has previously been a patient at the facility and already has a number can cause filing and MPI problems if a unit numbering system is used
•As explained earlier in the section about the MPI, two numbers assigned to a single patient are often referred to as "duplicate" numbers
What is the result the health record is being located using the health record number?
•Because the health record is located using the health record number, duplicate numbers result in the record having two separate locations and compromise the integrity of the MPI
•Thus, the importance of getting information correct the first time and at the point where it is initially collected, entered, or recorded cannot be overstated
•Figure 8.18 shows the various areas where patient registration can occur in a large healthcare organization
•In some organizations, responsibility for patient registration or admitting falls to the director of HIM services
•In others, the admitting department reports to nursing or some other unit or is a separate department
In smaller organizations such as freestanding clinics or long-term care facilities, patient registration usually occurs in, and is the responsibility of, only one area. In larger facilities:
•In larger facilities, it can occur in various areas •For example, when the patient is being admitted to an acute care hospital, registration usually occurs in the patient registration or admitting department
•However, when the patient comes to the emergency department for diagnosis or treatment, registration can occur in that department
•Still another scenario is that the patient is being seen for the first time in one of the healthcare facility's clinics
•In this case, patient registration occurs in the clinic office
How is documentation of information gathered during patient registration?
•Documentation of information gathered during patient registration is handled either electronically or in paper format
•Most acute care facilities now process all patient registration data using computer systems
•Although patients may complete a paper form, the registration clerk usually enters their information into a computer system
•In a smaller healthcare delivery unit such as a physician's office, however, registration data may still be collected and stored in a paper file
•The billing department also uses health record information that is entered into the computer by the HIM department
•The HIM department assigns clinical codes and abstracts information from the patient's health record that is required on the patient's bill •Therefore, the patient's bill cannot be submitted for payment until the HIM department enters the required health record information into the computer
The HIM department also affects the healthcare facility's reimbursement cycle by:
•The HIM department also affects the healthcare facility's reimbursement cycle by tracking health records where coding has been delayed and the bill has not been sent for payment
•In many facilities, a report is generated weekly that identifies patient accounts that have not been billed because of missing ICD-9-CM codes and/or CPT codes
•It is HIM personnel who locate the records to determine why there has been a delay in coding and initiate completion of the coding process so the bill can be submitted to the party responsible for payment of services
How can the ROI function in the HIM department also can affect the billing process?
Third-party payers often request additional information from the health record before payment (reimbursement for services provided) is sent to the healthcare facility.
Patient Care Departments: The HIM department
•The HIM department also works closely with patient care departments such as nursing, laboratory, radiology, physical and occupational therapy, and so on
•All patient care departments document the services they provide to patients in the health record
•Therefore, they are contributors to health record content
In a paper-based record system, the HIM department also delivers health records from previous admissions to the nursing units when the patient is readmitted to the hospital.
•In other healthcare settings, the HIM department pulls and delivers charts of established patients to clinics or other patient care areas
•When the patient is discharged from the hospital or leaves a clinic, the HIM department retrieves records from previous admissions or visits in addition to records of the patient's recent admission/visit
•The health record then is routed to the record-processing area of the HIM department
Information Systems: As the EHR is implemented the relationship between the HIM and IS departments becomes complex:
•It takes the expertise of both the HIM department and IS department to have a successful EHR
•The HIM professionals are the experts in health record content and provide knowledge of regulations to assure that records comply with federal, state, and accreditation standards
•The HIM professional also provides input to the efficient and effective health record information flow
•The HIM professional also understands privacy standards and protects health record content from unauthorized access
•The HIM professional is the resource person for the health record data needs of the facility
The IS department provide the experts to assure what?
•The IS department provide the experts to assure that the computer equipment and software are working properly
•The IS professional assures that the infrastructure needed to support the computer needs is in place
•The IS professional is responsible to assure that interfaces between computer systems work properly, system backups are completed in order to protect from the loss of data, software is installed and working properly, and computer equipment is maintained
With the transition to the EHR, the HIM department and IS department have partnered to assure:
•With the transition to the EHR, the HIM department and IS department have partnered to assure that the EHR functionality is realized to the fullest
•The HIM professional is the administrative EHR expert and the IS professional is the technical expert for a successful EHR
Participation on Medical Staff and Organizational Committees: HIM professionals frequently serve as liaisons or support personnel on various medical staff committees.
•For example, the HIT may be a member of the health record, quality management, or some other medical staff committee
•In a support capacity, the HIT may be responsible for taking minutes of the committee meeting, distributing the meeting agenda to committee members, and providing statistics or other required information
•As a liaison, the HIT's expertise is frequently required
•For example, serving on the organization's health record committee, the HIT may be asked to clarify policies, procedures, and accreditation requirements
Managing Documentation Requirements: The health record is the principal repository for data and information about the healthcare services provided to individual patients.
•Traditionally, the HIM department has been responsible for a variety of content issues
•In fulfilling this role, the HIM department has worked with appropriate medical staff committees, clinical departments, and administration
With regard to a paper-based health record, HIM usually sets standards for:
•Record content, chart order, and forms design and development to ensure that content meets accrediting, licensing, and other best practices for documentation
•HIM performs many of the same functions when working with an EHR
•The department helps ensure that record content and authentication (signatures) in the EHR meet accreditation and licensing requirements and also participates in user-interface design for computerized data input
Virtual HIM refers to:
•A health information management department that is not contained within the walls of a traditional facility
•Virtual HIM refers to the HIM functions traditionally performed within the walls of the healthcare facility being done remotely
•For the past several decades, many medical transcriptionists have worked from home •Digital dictation technology has allowed the medical transcriptionist to access dictation via phone lines or computer WAV files
•With the implementation of hybrid and electronic health record some facilities have permitted medical coders to work from home
As the full EHR is implemented, it is possible for what to happen?
•As the full EHR is implemented, it is possible for more of the HIM departmental functions to move to a remote location or to home-based work environments
•As paper-based functions are eliminated from the HIM workflow, it becomes possible to perform HIM functions from remote locations
•Additionally, virtual HIM also provides opportunities for HIM functions to be outsourced.
Accreditation and Licensing Documentation Requirements:
•Accrediting bodies such as the Joint Commission (TJC) and state licensing bodies are among the groups that have established standards for health record documentation
•The Joint Commission is a not-for-profit organization that offers an accreditation program for hospitals and other healthcare organizations based on pre-established accreditation standards (JCAHO 2005).
In addition to TJC, other entities that have established documentation standards include:
•Medicare Conditions of Participation
•National Committee for Quality Assurance (NCQA)
•American Accreditation Health Care Commission/Utilization Review Accreditation Commission (AAHCC/URAC)
•American Osteopathic Association (AOA)
•Commission on Accreditation of Rehabilitation Facilities (CARF)
•Health Accreditation Program of the National League of Nursing
•College of American Pathologists (CAP)
•American Association of Blood Banks (AABB)
•American College of Surgeons (ACS)
•Accreditation Association for Ambulatory Health Care (AAAHC)
•American Medical Accreditation Program (AMAP)
U.S. hospitals, as well as the majority of other healthcare organizations, seek Joint Commission accreditation.
•Joint Commission accreditation has been an indicator that the accredited hospital or healthcare facility provides high-quality care
•As part of the accreditation process, the healthcare facility undergoes an on-site evaluation by a team of Joint Commission surveyors
•It is during the survey that TJC evaluates the quality of care provided to patients, the systems in place for ensuring caregiver and medical staff competence, and the performance of important patient functions
•In the past, the on-site survey was a scheduled event.
The accreditation process includes:
A periodic performance review (PPR) and a priority focus process (PFP) that facilitates the newer continual standards compliance process.
Midpoint in the accreditation process, the hospital must submit:
•The PPR to the Joint Commission
•The PPR is a hospital's review of standards, compliance with standards, action plans implemented to address noncompliance with standards, and measures to follow up on the success of the action plans
The PFP uses information from the PPR and other data sources to identify:
•"priority focus areas" that are used to guide the survey process
•TJC survey, the PPR, and the PFP are used to indicate that the healthcare facility is in compliance with Joint Commission standards
Healthcare organizations accredited by TJC are also "deemed" to be in compliance with:
•The Medicare Conditions of Participation
•This is referred to as deemed status
•Medicare randomly selects hospitals recently surveyed by TJC and conducts another survey to validate TJC survey results
It is essential that HIM professionals become familiar with TJC and Medicare standards and documentation requirements.
It is important to note that each accrediting and licensing agency has its own standards, which must be followed by the healthcare facilities under their auspices.
Monitoring of Accreditation, Licensure, and Standards Requirements: No program for ensuring the quality of health record content would be complete without a process for monitoring accreditation, licensure, and other federal or state agency requirements.
•Good documentation practices require organizations to be in compliance with regulations and standards from a variety of groups
•The HIM department director should establish a mechanism that targets specific regulatory or standards groups and monitors for compliance with these standards
•New standards and changes to regulations must be monitored and HIM functions revised if necessary
•Because the HIM department's functions include review and analysis of the health record, several processes are typically in place to monitor the healthcare facility's compliance with Joint Commission standards
Following are examples of the typical processes in place within the HIM department to monitor compliance: Record completion process
—Monitoring delinquency rates: As part of its record completion processes, the HIM department monitors the number of delinquent records
•Many facilities determine the number of delinquent records each month and notify their medical staff members of their incomplete and delinquent records
•The HIM professional determines the quarterly medical record delinquency rate for the facility and determines whether the hospital is in compliance with Joint Commission standards
•If the hospital is not in compliance with TJC, the medical records committee, administration, and other appropriate parties are notified and corrective is action taken
•There may be various consequences for physicians when they have not completed delinquent charts within a specified period of time
—Monitoring timely completion of medical reports: Other Joint Commission standards specify time frames within which various medical reports (history and physicals, operative reports, autopsy reports, and so on) must be completed
•The HIM department's transcription area may monitor compliance in this area
•The transcriptionist can compare the date a report was dictated against the date of service or admission to determine whether the report has been completed within the time frame specified by the standards.
—Monitoring health record completion: The quantitative analysis function of the HIM department monitors whether health record documents have been authenticated
•Unauthenticated parts of the health record are identified for completion by either handwritten or electronic signature
•If the physician does not complete the record within a timely manner, the record is counted in the delinquent record rate.
Following are examples of the typical processes in place within the HIM department to monitor compliance: Documentation
—Monitoring the use of abbreviations, acronyms, and symbols:
Transcriptionists can assist with monitoring the use of abbreviations, acronyms, and symbols as they transcribe dictation
•Clinical coding personnel also can identify the use of unauthorized abbreviations, acronyms, and symbols as they abstract information from health records
•This is an example of the HIM professional's role in monitoring hospital compliance with TJC's standard on abbreviation usage in the health record
Following are examples of the typical processes in place within the HIM department to monitor compliance: Confidentiality of information
—Monitoring access to protected health information:
The HIM department's daily ROI activities can help ensure and monitor access to patient-specific information after discharge
•HIM personnel are knowledgeable in the laws and regulations governing the release of patient information
•Thus, the department's ROI function is instrumental in monitoring compliance with Joint Commission standards regarding access to protected health information.
Following are examples of the typical processes in place within the HIM department to monitor compliance: Access to patient records
—Storage and retrieval processes: The storage and retrieval processes are managed to ensure that health information is accessible for patient care. These processes are pivotal for compliance with the Joint Commission standards
There are many additional Joint Commission standards that help healthcare organizations improve quality of care and patient safety:
•For example, TJC also has a list of abbreviations that may not be used in the healthcare facility, because these abbreviations may be misinterpreted
•The HIM professional must consult the Comprehensive Accreditation Manual for Hospitals published by TJC for a complete listing of standards and elements of performance
•TJC also publishes accreditation manuals for specialty areas, such as long-term care and behavioral healthcare facilities
•In addition to monitoring performed as part of daily HIM functions, health record reviews are often done periodically to ensure facility compliance with other standards
•The health records review process is a multidisciplinary process coordinated by the HIM department
Management and Supervisory Processes: Regardless of size, all HIM departments involve a great deal of organization, management, and supervision of personnel.
•This section provides an overview of some of the more common supervisory responsibilities associated with the management of the HIM functions
•Chapter 18 also provides a detailed discussion on management and supervisory issues
Policy and Procedure Development: Policies and procedures serve as the foundation for the management and supervision of employees of any department or unit.
•Policies are statements that describe general guidelines that direct behavior or direct and constrain decision making in the organization. •Some policies apply to the entire organization; departmental policies apply only to specific business units
Policies follow a specific format. For example:
•The policy statement from the University of Houston shown in figure 8.19 provides a specific format that includes a policy title, description of the scope of the policy, the expected standard, and guidelines to achieve the expected standard (University of Houston 2001)
•Figure 8.20 is an example of a policy that provides guidance for the assignment of overtime within the HIM department
•Every policy must be dated, and if there has been a revision, the date of the revision also should appear on the policy
•The format of a policy statement varies from organization to organization.
Figure 8.19. Simple policy on computer terminal controls
Purpose: To prevent unauthorized access to University Hospital data by providing terminal controls
Scope: University Hospital's terminals
Standard: Proper physical and software control mechanisms shall be in place to control access to and use of devices connected to University Hospital's computer systems
1. Hardware Terminal Locking: In areas that are not physically secured, terminals should be equipped with locking devices to prevent their use during unattended periods. The locks should be installed in addition to programmed restrictions, such as automatic disconnect after a given period of inactivity
The success of policy relies on procedures.
•Unlike broad statements included in a policy, procedures are specific statements about how work is to be carried out
•Essentially, they are specific instructions to help employees carry out a function or activity •Procedures provide step-by-step instructions on how to complete a specific task
•Written procedures are beneficial as a training tool for new employees
•They also are beneficial for providing staff with a consistent method of completing tasks
The format of procedures varies from facility to facility. Figure 8.21 is an example of a procedure that explains the process of collecting discharge records from the nursing unit.
•This procedure demonstrates the detail that should be included in a written procedure
•This procedure also demonstrates the interrelationship of the HIM department with the nursing units and the intra-relationship among the different functions of the HIM department
Health information technicians have to follow both policies and procedures in their job functions:
•In some instances, the HIT will be involved in the development of policies and procedures as they pertain to the HIM department or information management in the organization. •Figure 8.22 provides a listing of common HIM policies and procedures
Figure 8.22. Common HIM department policies and procedures
The following list provides an example of the types of policies and procedures that may be included in a manual for health information services. The titles and content of the policies and procedures may vary by facility or corporation. Some of the policies and procedures are listed more than once for cross-referencing purposes
Access to Automated/Computerized Records
Access to Records (Release of Information) by Resident and by Staff
Facility Procedures—Establishing/Closing the Record
Preparing the Medical Record
Preparing the Master Patient Index Card
Readmission—Continued Use of Previous Record
Amendment of Clinical Records
Audit and Monitoring System
Specialized Audits (examples)
Change in Condition
Nursing Assistant Flow Sheet
Psychotropic Drug Documentation
Chart Removal and Chart Locator Log
Clinical Records, Definition of Records, and Record Service
Access to Records
Automation of Records (See also Computerization)
Change in Ownership
Coding from home
Completion and Correction of Records
Definition of the legal record
Ownership of Records
Permanent and Capable of Being Photocopied
Storage of Records
Willful Falsification/Willful Omission
Closing the Record
Coding and Indexing, Disease Index
Committee Minutes Guidelines
Computerization and Security of Automated Data/Records
Confidentiality (See Release of Information)
Consulting Services for Clinical Records and Plan of Service
Content, Record (the list provided is not all-inclusive and should be tailored to the facility/corporation)
Transfer Form/Discharge Plan of Care
Discharge against Medical Advice
Physician Consultant Reports
Physician Orders/Telephone Orders
Physician Services Guidelines and Progress Notes
Physician History and Physical Exam
Interdisciplinary Progress Notes
Copying/Release of Records—General
Correcting Clinical Records
Definition of Clinical Records/Health Information Service
Delinquent Physician Visit
Denial Letters, Medicare
Destruction of Records, Log
Disaster Planning for Health Information
Assembly of Discharge Record
Chart Order on Discharge
Completing and Filing Master Patient Index Card
Discharge Chart Audit
Notification of Deficiencies
Incomplete Record File
Closure of Incomplete Clinical Record
Preparation of the record, imaging of records, quality review
Emergency Disaster Evacuation
Falsification of Records, Willful
Filing Order, Discharge (Chart Order)
Filing Order, In-house (Chart Order)
Filing System, Unit Record
Forms, Release of Information
Guide to Location of Items in the Health Information Department
Guidelines, Committee Minutes
Incomplete Record File
Disease Index and Forms for Indexing
Master Patient Index
Release of Information Index/Log
In-service Training Minutes/Record
Health Information Coordinator
Health Unit Coordinator
Other Health Information Staff (if applicable)
Master Patient Index
Certification and Recertification
Medicare Denial Procedure and Letter
Ombudsman, Review/Access to Records
Order of Filing, Discharge
Order of Filing, In-house
Organizational Chart for Health Information Department
Orientation/Training of Health Information Department
Physician Visit Schedule, Letters, and Monitoring
Physician Visits, Delinquent Visit Follow-up
Health Information Participation
QA Studies and Reporting
Readmission—Continued Use of Previous Record
Recertification or Certification (Medicare)
Reconstruction of Lost Record
Refusal of Treatment
Release of Information
Confidentiality Statement by Staff
Copying/Release of Records—General
Faxing Medical Information
Procedure for Release—Sample Letters and Authorizations
Redisclosure of Clinical Information
Resident Access to Records
Retrieval of Records (sign-out system)
Uses and disclosures of protected health information, uses and disclosures of deidentified documentation, business-associated contracts, audit trails
Witnessing Legal Documents
From Hospitals and Other Healthcare Providers
Request for Information Form
Retention of Records and Destruction after Retention Period
Example Statement for Destruction
Retrieval of Records
Security of Automated Data/Electronic Medical Records
Storage of Records
Maintaining Overflow Record
Unit Record System
•A budget is a plan that converts the organization's goals and objectives into targets for revenue and spending
•Essentially, it is a type of planning tool as well as an evaluation tool.
An organization's budget has many components, including:
•A revenue budget is a prediction of how much money an organization's activities will generate during a certain period.
•An expense budget is a prediction of how much expense an organization is going to generate. The expense budget includes things such as employee salaries and supplies.
•A capital budget is a projection or plan of what the organization intends to spend on long-lived assets such as a piece of equipment.
•A cash budget is the anticipated flow of cash into and out of the organization
Most often, HITs use expense and capital budgets
•Most budgets are created for an entire year
•In fact, the budgeting process may begin several months before the budget period begins
•For example, department directors may be asked to submit their estimates regarding revenue and expenses to upper management in July for a budget period that actually begins the following January
•After upper management receives the department director's budget projections, the director usually has to explain and justify them at a hearing before a budget committee or senior management
•At or after the budget hearing, the department director is given feedback, negotiations are undertaken, and adjustments are made. Senior management makes the final budget allocations
The HIT may be involved in helping to develop the departmental budget. This may include:
•Providing information about resource and staffing requirements that are anticipated to increase or decrease in the coming year
•These types of requirements are based on considerations such as work volume, staffing needs, changes in departmental functions, and so on
•For example, when senior managers predict that the volume of inpatients is going to increase in the next year, the increase may affect HIM department resources and staffing
•The increased volume of patients might be reflected in the need to purchase more file folders. There will be increased dictation and thus transcription of medical reports
•Additionally, there will be more health records to store and file. Such increases will have a direct impact on the HIM department's budget
Because the budget is both an evaluation tool and a planning tool, the HIT may have to evaluate variances from the budget.
•A variance analysis is a report that compares actual amounts of expense and revenue to the amounts that were originally budgeted
•The variance report answers the question about how far away actual expenses and revenues are from the targeted budget amounts
•Budget variance reports are usually provided every month to department managers so that they can keep track of actual-versus-projected revenue and expenses and take appropriate action to try to stay within the projected budget
Performance Review and Appraisal
•An important part of any management job is conducting employee performance reviews and appraisals
•This activity falls within the scope of supervision of HIM functions
•To conduct employee appraisals, the HIM department must have policies, procedures, job descriptions, and work standards in place. •Chapters 11 and 18 discuss performance assessment concepts and practices.
Future Directions in Health Information Management Technology: The role of the HIM professional continues to evolve as healthcare and technology evolve. Some of the factors influencing the evolution of the role of HIM professionals are as follows:
•Expansion of network capabilities
•Emergence of new technologies such as EHRs, natural language processing, and computer-assisted coding
•Move toward ICD-10-CM and ICD-10-PCS
•Societal and regulatory requirements for information privacy and security
•Greater demand and accountability for improved healthcare quality and patient safety that can be facilitated through the use of information technology
•Increased consumer knowledge of personal healthcare decisions and increased focus on personal health records
Hospitals in the United States spend billions of dollars annually to store and manage both paper and electronic health records. The ever expanding wealth of patient information increasingly strains the U.S. economy. President Obama has made electronic recordkeeping a key feature of his healthcare reform effort:
•The ARRA of 2009 provides funds to promote the use of interoperable, certified health information technologies including EHR adoption
•ARRA provides financial assistance and incentives necessary for the transition to electronic health records
•The Office of the National Coordinator for Health Information Technology (ONC), a federal entity located within the Office of the Secretary for the U.S. Department of Health and Human Services (HHS), is responsible for the coordination of the national initiative that all providers adopt an EHR by 2014
•The ONC was established in 2004 and in February 2009 the ARRA expanded the role of this office to further support the EHR initiative through funding and the establishment of standards (ONC 2009)
It has been said that we are currently in the information age. In part, this means that:
•Information is recognized as a commodity with value
•As part of the information age, an explosion of information technology (IT) is transforming the workplace
•Many healthcare facilities have either implemented an EHR or are in the transitional stages of implementing one; however, many of the EHRs today use a large amount of imaged documents
•As EHRs evolve, the expanded use of database technology and direct data input will be necessary to meet industry standards and demands for information
The Internet and the IT explosion have transformed HIM functions and will continue to contribute to the evolution of the HIM professional's role:
•In addition to making EHRs possible, technology is transforming specific work tasks. •The IT explosion continues to break down the brick and mortar of the HIM department, making virtual HIM a viable option as HIM departments restructure and adopt the EHR. •Similarly, the Internet and its capabilities are beginning to affect the role of the clinical coder. •As the EHR is implemented, more and more facilities are allowing staff to code from remote locations.
As technology and the EHR continue to evolve, what is not unrealistic to expect in NLP?
Natural language processing (NLP) will improve to the point that auto-coding could become a reality.
Is the process in which digital text stored on computer can be read by software and automatically coded. If or when NLP is implemented, the role of the clinical coder would most likely be reengineered and used for quality control of the automated process.
Perhaps a more immediate influence likely to affect the role of the clinical coding professional is:
•Implementation of ICD-10-CM and ICD-10-PCS. The ICD-10-CM and ICD-10-PCS coding systems will replace ICD-9-CM for coding diagnoses and procedures
•Implementation of the revised or new coding systems will require that clinical coders be retrained to use them
•Moreover, it will require software vendors to provide new products, which could expand opportunities for HIM professionals
Because information transcends boundaries, the HIM department may not be a department at all in the future, but instead may become:
•A function that is integrated throughout the organization and exists in many departments. •Thus, the HIT may be working in information functions managed by departments other than health information management
•Evidence suggests that this phenomenon is already occurring as HIM professionals move into roles in data security, organizational compliance, health data analysis, medical staff services, and so on.
The AHIMA Vision 2016
•Prioritizes the need to revamp the associate degree-level HIM professional from a "generalist to a technical specialist by 2016" (AHIMA Vision 2016 2007)
•Vision 2016 also discusses the need to provide a pathway for advanced practice role for HIM professionals through the development of graduate degree programs.
AHIMA outlined the following roles as those most likely to evolve:
•The health information manager (a line or staff manager) would have enterprise- or facility-wide responsibility for health information management
•The position includes working with the chief information executive and system users to advance systems, methods, and application support and to improve data quality, access, privacy, security, and usability
•The clinical data specialist would perform data management functions in a variety of application areas, including clinical coding, outcomes management, specialty registries, and research databases
•The patient information coordinator would perform new service roles that help consumers manage their personal health information, including personal health history management, ROI, managed care services, and information resources
•The data quality manager would perform functions involving formalized continuous quality improvement for data integrity throughout the enterprise, beginning with data dictionary and policy development and including quality monitoring and audits
•The data resource administrator would be responsible for the next generation of records and data management using media such as the CPR, the data repository, and electronic warehousing for meeting current and future care needs across the continuum, providing access to the needed information, and ensuring long-term integrity and access
•The research and decision support analyst would support senior management with information for decision making and strategy development using a variety of analytical tools and databases
•The position would work with product and policy organizations on high-level analysis projects such as clinical trials and outcomes research
•The security officer would manage the security of all electronically maintained information, including the promulgation of security requirements, policies and privilege systems, and performance audits
Some HIM professionals have taken the role of security officer as the healthcare facility implements measures to comply with HIPAA. Others have assumed the role of:
•Facility- or enterprise-wide health information managers as healthcare facilities are transitioning toward the EHR
As AHIMA Vision 2016 predictions continue to become a reality, new roles for the HIM professional will continue to emerge. "New roles may include:
Business change manager, EHR system manager, IT training specialist, business process engineer, clinical vocabulary manager, workflow and data analyst, consumer advocate, clinical alerts and reminder manager, clinical research coordinator, privacy coordinator, enterprise application specialist, and many more"
Many of these positions will fall outside traditional roles and workplaces. Most will call for?
•Additional skills and education.
•Yet, with their unique mixture of clinical and information skills, HITs are poised for success
Further evidence of the changing role of the HIM professional is noted in the HITECH provision of the ARRA. The HITECH component of the ARRA provides funding to community colleges to train individuals in the following roles:
•Practice workflow and information management redesign specialists
Implementation support specialists
•Technical/software support staff
As a result of the expected change in job functions, the conclusion drawn from AHIMA was that:
•Trend data indicate that employers in the twenty-first century will require flexible and multi-skilled workers
•Employers also will demand that employees continually add to their skill sets to meet changing needs
•That is why another fundamental principle of AHIMA is the need for lifelong learning
•HIM professionals must be committed to ongoing education and professional development
Check Your Understanding 8.8
1. If one needed to know the number of C-sections performed by a specific obstetrician, which of the following indices would be used to identify the cases?
A. Operation index
Check Your Understanding 8.8
2. The computer system that may serve as the MPI function is the:
A. Patient registration system
Check Your Understanding 8.8
4. What department within the hospital uses the information abstracted and coded by the HIM department to send for payment from third-party payers?
C. Billing department
Check Your Understanding 8.8
5. The function within the HIM department responsible for listening to dictated reports and typing them into a medical report format is called:
B. Medical transcription
Check Your Understanding 8.8
6. Reviewing requests for health record copies and determining if they are valid is part of what function within the HIM department?
D. Release of information function
Check Your Understanding 8.8
8. One of the most sought after accreditation distinction by healthcare facilities is offered by the:
C. Joint Commission
Check Your Understanding 8.8
9. Statements that describe general guidelines that direct behavior or direct or constrain decision making are called:
Check Your Understanding 8.8
10. Step-by-step instructions on how to complete a specific task are called:
Check Your Understanding 8.8
11. The departmental budget is both an evaluation tool and what type of tool?
Check Your Understanding 8.8
13. The purchase of an EHR system would be planned for in what type of budget?
Check Your Understanding 8.8
14. Assigning ICD-9-CM and CPT codes to the diagnoses and procedures documented in the medical record is called:
A. Clinical coding