The Strategic Importance of Electronic Health Records Management

Transcription

1 The Strategic Imprtance f Electrnic Health Recrds Management Mre than ever, the healthcare industry is making significant prgress in the quest fr electrnic health recrds (EHRs), which will imprve the quality and safety f patient care and achieve real efficiencies in the healthcare delivery system. Emphasis has been placed n intelligent systems that supprt the care prcess and clinical decisins as well as the creatin f health infrmatin fr patient care. Frm a strategic standpint, it is imprtant t g beynd the infrmatin creatin phase and develp a plan that results in an EHR and EHR system that maintain a high level f integrity fr business and legal purpses. The management f the EHR and the EHR system is and will cntinue t be a missin-critical functin in the prvisin f care acrss the healthcare cntinuum. Hwever, in tday s urgency t begin deplying EHRs, healthcare entities, vendrs, and thers smetimes neglect t build in the prcesses and system capabilities needed t enable ptimal EHR management functins and ensure the electrnic rather than the paper versin can stand as the legal business recrd. Traditinal business and health recrds management cncepts and prcesses must be evaluated and applied in this relatively new wrld f EHRs. Business prcess redesign and an understanding f the change management prcess are fundamental t this activity. Healthcare rganizatins need t analyze and assess all dwnstream uses f EHRs and see thse uses reflected in requests fr prpsals, system selectin, develpment, installatin, and implementatin in rder t ensure that all needs f the rganizatin are met. Definitin f Electrnic Health Recrds Management Electrnic health recrds management (EHRM) is the prcess by which electrnic (e.g., digital) health recrds are created r received and preserved fr evidentiary (e.g., legal r business) purpses. An electrnic recrd includes infrmatin that is: Recrded n any electrnic medium (e.g., magnetic medium) Intended t prvide dcumentatin fr lng-term retentin that has legal r business evidentiary value Ptentially prduced in respnse t a subpena duces tecum EHRM requires decisin making and planning thrughut the entire life cycle f the EHR frm planning, prcessing, distributin, maintenance, strage, and retrieval f the health recrd t its ultimate dispsitin, including archiving r destructin. Decisin making includes, but is nt limited t, what EHRs t keep and fr hw lng, the assignments f authrities and respnsibilities, the design and administratin f the prcess, and the audit and review f the prcess s perfrmance. In the early phases f EHRM system develpment, it is imprtant t make critical decisins abut the rle and use f paper and film t avid the dilemma f maintaining dual systems. Rles and Respnsibilities HIM ensures the availability f clinical, demgraphic, financial, and administrative data t facilitate realtime healthcare delivery and critical health- and business-related decisin making fr multiple purpses Page 1 f 30

2 acrss diverse rganizatins, settings, and disciplines. HIM prfessinals are ideally suited t prvide the healthcare entity with the necessary leadership t ensure that the EHR and the EHR system are ptimally managed. As the traditinal custdian f the paper medical recrd and medical recrd system, HIM prfessinals are trained t ensure the quality, privacy, and integrity f the EHR. Tday, the EHR can and ften des reside in several different infrmatin systems. HIM prfessinals ensure that infrmatin management standards are cnsistently applied acrss these varius systems in rder t maintain the level f integrity necessary fr the healthcare rganizatin s recrds. The evlutin frm a paper-based medical recrd mdel t an EHR mdel has pened up many avenues fr HIM experts t apply and share their cre cmpetencies, knwledge, and skills. Advanced technlgies and systems make it pssible fr HIM practitiners t fulfill rles such as patient advcate, data translatr, and public health fficer. The e-health envirnment encmpasses much mre than the strage and retrieval f infrmatin. It places new demands n the HIM prfessinal t assist the cnsumer in healthcare acrss the cntinuum f care. As a patient advcate, HIM practitiners have a vital rle and respnsibility in the use f patient prtals fr , persnal health recrds, scheduling healthcare appintments, cmpleting patient health questinnaires and surveys, and transferring electrnic clinical infrmatin. HIM practitiners play a rle in wrking tward the exchange f healthcare data amng prviders, healthcare prfessinals, and patients. Other traditinal patient advcate respnsibilities, such as prtecting patient privacy, maintaining cnfidentiality, and prmting and enhancing public plicy, will cntinue t be a critical HIM respnsibility. HIM prfessinals have lng been translatrs f clinical data fr their business and financial ffices thrugh their clinical expertise, understanding f dcumentatin, and cding functins. Nw is the time fr HIM practitiners t share their knwledge with healthcare cnsumers in the rle f data translatr. The shift t a cnsumer-centric mdel requires HIM practitiners t educate and assist cnsumers in accessing secure patient infrmatin and translating medical terminlgy acrss the cntinuum f care and in advanced technlgies. The e-health envirnment is, therefre, increasing the ability f HIM prfessinals t manage data and assist in the develpment f decisin supprt systems fr individual, aggregate, and public health data. HIM practitiners have a tremendus respnsibility in prviding the supprt fr rganizatinal, lcal, and natinal systems that ensure quality, integrity, and availability f healthcare data. The rle f the public health fficer in prviding strategic leadership f health infrmatin in the public health sectr has been gaining imprtance such that we may, in fact, say that these activities are already underway and can be fully supprted by the EHR. The EHR and EHRM are expanding the rles and respnsibilities f HIM practitiners. Legal, regulatry, and accrediting envirnments will need t adapt t the emergence f new technlgies and applicatins in healthcare, and s the traditinal leadership rle f HIM will cntinue t influence and adapt the management f health infrmatin. Checklist fr Transitin t the EHR Additinal Material While this practice brief prvides an verview f the imprtance f strategic electrnic dcument management, much supprting infrmatin is necessary t make a successful transitin t the EHR. These cnsideratins are included in the nline appendix t this practice brief. Appendix A: Issues in Electrnic Health Recrds Management Page 2 f 30

3 References AHIMA. A Visin f the E-HIM Future: A Reprt frm the AHIMA E-HIM Task Frce Available nline at HIM Prfessinals Vital in Transitin t e-him. AHIMA Advantage 7, n. 6 (2003): 1, 3 4. Prepared by Beth Acker, RHIA Debra Adams, RN, RHIA, CCS, CIC Camille Cunningham-West, RHIA Michelle Dugherty, RHIA, CHP Chris Ellitt, MS, RHIA Cathy Flite, M.Ed., RHIA Maryanne Fx, RHIA Rnna Grss, RHIA Susan P. Hansn, MBA, RHIA, FAHIMA Debrah Khn, MPH, RHIA, CHE, CPHIMS Tricia Langenfelder, RHIA Beth Liette, RHIA Mary Ellen Mahney, MS, RHIA Carl Ann Quinsey, RHIA, CHPS Dnna J. Rugg, RHIT, CCS Cheryl Servais, MPH, RHIA Mary Staub, RHIA, CHP Anne Tegen, MHA, RHIA, HRM Lydia Washingtn, MS, RHIA, CPHIMS Kathy Wrazidl, RHIA Acknwledgements Darice Grzybwski, MA, RHIA, FAHIMA Kelly McLendn, RHIA The AHIMA Electrnic Health Recrds Management wrk grup is funded by a grant t the Fundatin f Research and Educatin (FORE) frm Precyse Slutins. Article citatin: AHIMA e-him TM Task Frce. "The Strategic Imprtance f Electrnic Health Recrds Management." Jurnal f AHIMA 75, n.9 (Octber 2004): 80A-B. Cpyright 2004 American Health Infrmatin Management Assciatin. All rights reserved. Page 3 f 30

4 The Strategic Imprtance f Electrnic Health Recrds Management: Checklist fr Transitin t the EHR This checklist assists in the transitin frm paper t an electrnic health recrd (EHR) as a legal medical recrd. Whether paper r electrnic, the system must meet certain standards t be cnsidered a legal business recrd. This checklist will help yur rganizatin with the preparatin fr ging paperless and ensure that when yu d, yu can get rid f the paper. Once the decisin t mve t an EHR system is made, rganizatins must address the change in culture fr ging paperless. If an rganizatin embraces technlgy fully, this may be an easy task. If an rganizatin has deeply embedded traditins, this task may be quite arduus. Hwever, if rganizatins d nt fully embrace the change, the migratin t an EHR system will be destined t fail. The decisin t g paperless invlves having enugh cnfidence in the electrnic system t let g f the paper system. This which includes ensuring that the system handles amendments, crrectins, authenticatin, backups, dwn time, cnfidentiality, and printuts and reprts fr disclsure purpses. Getting Started Frm an executive-level cmmittee (ELC) t review and apprve the change t a fully electrnic system. Obtain executive-level supprt that will review and apprve the migratin. Frm an rganizatinal-level cmmittee, empwered by the ELC, management, and all members f the rganizatin t establish and implement plicies and prcedures required t manage the change t a paperless system frm start t finish. Review and revise yur legal health recrd plicy. This shuld be a cmprehensive plicy that describes each step invlved in the transitin. This may mean planning fr a hybrid envirnment (bth paper and electrnic). Develp a cmprehensive plan f actins and milestnes that details each step invlved in the mve t a fully electrnic system. This plan shuld cntain a definitive date fr the cmpletin f the migratin and shuld detail individual departmental r divisinal rllut dates. Cnsider the fllwing when setting the date and defining the prcess: Is it fr all patients seen after a certain date? Fr all dcuments created after a certain date? Fr all patients discharged r admitted by a certain date? Will yu transitin all areas f the rganizatin at nce r individually? Will yu transitin by unit r by dcument type (e.g., lab then radilgy then transcriptin)? Develp a cmprehensive data map f all rganizatinal wrkflws and prcesses that may be affected by the transitin t an electrnic system. This data map shuld address bth administrative and clinical wrkflws. After an rganizatinal review f these data maps, cnsider apprpriate steps t reengineer and redevelp wrkflws as apprpriate. Develp cmprehensive prcesses and prcedures that address the cnversin f paper-based dcuments t an electrnic frm. Develp a cmmunicatins plan that prvides the rganizatin with a clear understanding f the change prcess invlved in mving tward a fully electrnic system. The plan shuld address the respnsibilities f all individuals within the rganizatin (clinical and nn-clinical staff). Educatin and infrmatin tasks shuld be incrprated int the plan. Cnsider the use f letters, psters, fliers, , r presentatins with a clear message f the change. During the transitin, cnsider develping a grid r matrix that describes where and hw t find specific dcument types (e.g., histry and physical exam frms, perative reprts, discharge summaries, physician rders, test results). Review the practice brief The Cmplete Medical Page 4 f 30

5 Research Recrd in a Hybrid EHR Envirnment, available in the FORE Library: HIM Bdy f Knwledge at Research state regulatins (e.g., defining the electrnic recrd, retentin f recrds, electrnic signatures). Research applicable accreditatin standards: Jint Cmmissin n Accreditatin f Healthcare Organizatins standards (e.g., Standard IM.2.20 addresses data integrity, IM.2.30 addresses cntinuity and disaster recvery fr bth hard cpy and electrnic recrds) Cmmissin n Accreditatin f Rehabilitatin Facilities Research federal laws (e.g., HIPAA and the Privacy Act f 1974 if they apply t yur rganizatin). Review the Federal Rule f Evidence, Article VIII. The EHR shuld meet the federal and state rules f evidence t stand as a legal business recrd. Review the practice brief Maintaining a Legally Sund Health Recrd, als available at fr a summary f the rules f evidence. Research applicable FDA regulatins: 21 CFR 11: Electrnic Recrd and Electrnic Signatures Regulatin FDA Guidance fr Industry-Cmputerized Systems Used in Clinical Trials 45 CFR 46: Prtectin f Human Subjects If apprpriate t yur facility, review the applicable federal cnditins f participatin (e.g., defining the electrnic recrd, retentin f recrds, electrnic signatures). 42 CFR 2: Cnditins f Participatin fr Drug, Alchl, and Substance Abuse 42 CFR 418: Cnditins f Participatin fr Hspices 42 CFR 482: Cnditins f Participatin fr Hspitals 42 CFR 483: Cnditins f Participatin fr Lng Term Care Facilities 42 CFR 484: Cnditins f Participatin fr Hme Health Agencies 42 CFR 485: Cnditins f Participatin fr Rehab Seek ut prfessinal peers wh may be wrking thrugh this same issue in yur lcal cmmunity, as well as yur state and natinal cmmunities. Jin different AHIMA Cmmunities f Practice (e.g., E-HIM, Enterprise Imaging, HIPAA: Cmputer-based Patient Recrd). Cntent Issues Cnsider the fllwing issues related t cntent: Can patient infrmatin be efficiently and legibly accessed and retrieved? Des dcumentatin indicate the exact date and time f the recrding f the event and the name f the dcumenter? Is this infrmatin viewable? Printable? Hw will versining f the electrnic recrd prcess wrk? Hw will the riginal unaltered versin and edits be maintained? Hw can yu tell whether the reprt has been edited? Hw lng after an entry has been made can the dcumentatin be crrected r amended? Amendment rules shuld be similar t thse in the paper wrld. The change, date and time, and authr f the change shuld be viewable and printable. The rule fr crrecting data and reprts shuld be the same fr paper and electrnic systems. Evidence f the crrectin with the date and time and authr f the change shuld be viewable and printable. If a patient requests an amendment r crrectin, hw will it happen in the EHR system? Will the infrmatin be scanned r imprted as a text file int the recrd? Hw will yu knw the recrd is finalized r cmpleted n the system? Paper r paperless, recrd cmpletin business prcesses will still be needed. Hw will temprary dcumentatin (e.g., preliminary findings, draft reprts, unsigned and authrized reprts) be clearly identified? Page 5 f 30

6 Frmat Issues What is the data validity and cmpletin prcess? Will physicians cmplete recrds nline? Hw will they knw t d that? Will yu give them a break n suspensins during the learning curve and still be in cmpliance with the Jint Cmmissin? Will the EHR system allw electrnic signatures that meet state and federal law? Is the signature viewable? Printable? Will the EHR system allw required c-signatures (e.g., students, residents, nurse practitiners)? Is the signature viewable? Printable? Hw will dcumentatin reviews be perfrmed (e.g., medical recrd reviews)? Have individuals wh d data abstractin, utilizatin review, r auditing been trained t identify where t find infrmatin? Cnsider the fllwing issues regarding frmat: Cnsider befre and after frmats cmparing the paper dcument t the cmputergenerated dcumentatin. Is there a cmparable electrnic versin f each dcument? Will yu realign rles and respnsibilities fr existing cmmittees (e.g., will the frms cmmittee apprve the frmat f the electrnic recrd)? Hw shuld the recrd be rganized? Is the infrmatin in the recrd rganized fr efficient retrieval f needed data? Is it readable? Can the recrd be brught t paper in a readable frmat? Are there custmizable views fr different grups f users (e.g., clinical view, HIM view, audit view)? If alerts and reminders are part f a legal medical recrd, are they viewable? Printable? Plan fr auditr access t the recrd nline withut the ability t see r search fr ther patient recrds an auditr is nt privileged t view. Hw will the auditr be trained t use the system? Hw will staff be trained t read thrugh the nline recrd t find infrmatin? If cpies need t be printed ut f the system, ask if the system can label printed reprts t include a prminent watermark r label with infrmatin abut dispsing f the cpy r print the reprt n clred paper. Hw will yu integrate paper frm utside the facility? Will it be scanned immediately r kept in a temprary paper flder fr a perid f time? Plicy and Prcedures Cnsider the fllwing issues related t plicy and prcedures: D rganizatinal plicies need revisin in respnse t issues identified with ging paperless? Address retentin fr electrnic recrds. It is critical t verify hw lng dcuments r data is readily available frm varius systems. Des the electrnic data g away after a cuple f years? Hw lng will data be kept nline? After archived, hw will it be retrieved? If a recrd must be thinned, hw will yu g abut it? Hw will this infrmatin be retrieved? What is the dwntime (manual backup system) plicy and prcedure? Will dcuments cmpleted while the system is dwn be part f the legal medical recrd? Will they be scanned int the recrd? Will printing be restricted? Unrestricted printing means yu are nt paperless. (Fr a discussin n the prs and cns f printing, see the practice brief The Cmplete Medical Recrd in a Hybrid EHR Envirnment. Part III: Authrship f and Printing the Health Recrd. ) Page 6 f 30

7 Cnfidentiality Determine where cpies may be printed in the rganizatin and methds t be used fr cpy dispsal. Will there be an audit trail t identify users wh have printed reprts frm the system? Cnsider the fllwing cnfidentiality issues: Will patients have nline access t their medical recrds? If nt, yu will have t print the recrd fr their review. Hw will the release f infrmatin functin be cmpleted? Can the recrd be attached t an , faxed, stred n a CD, r printed? Review HIPAA requirements. Is the system HIPAA cmpliant? Shuld nurses and ther caregivers be restricted t viewing nly the patients n the unit where they are assigned? What abut physician access t recrds when they are nt recrded as a treating physician (e.g., cnsultants, referring physicians, physicians ding cmmittee reviews, researchers)? Can any physician n staff have access t any patient recrd? Hardware Define yur hardware platfrm. Are yu using a high-availability platfrm r a stand-alne platfrm? Is there a redundant r mirrr database r system server? Define the backup prcess, including media, retentin, and rtatin cycle. Test it. Define the disaster recvery prcess and the acceptable dwntime. (There will be system maintenance windws r system upgrades.) Is there enugh hardware available fr access? Plan fr access pints acrss the facility fr physicians, nurses, all caregivers, and nn-clinical reviewers. Cnsider budgetary issues fr yur department (e.g., additinal printers, supplies, persnal cmputers). Interfaces Plan fr interfaces (e.g., lab, ADT, radilgy). Hw ften is infrmatin transferred t ther systems? What is the recnciliatin prcess? Is there an interface fr the master patient index t the EHR system s that medical recrd numbers merged in the index will be autmatically merged in the EHR system? Or will staff have t g in and ut f different systems t keep the medical recrd numbers accurate? Lessns Learned As the saying ges, experience is the best teacher. Here are sme lessns learned by ther HIM prfessinals as they have made the transitin frm a paper-based t an EHR: Take the time t visualize the wrkflw f all HIM functins supprting a paperless health recrd. Yu will experience a number f a-ha! mments. This is critical t the planning phase. T be successful, it will be necessary t map the transitin frm paper t paperless by carefully cnsidering all the changes that may r will ccur. Encurage yur staff t assist yu in this visualizatin prcess. Cntinuusly asking what if? will allw yu t discver many f the imprtant issues during the planning stage. During the planning stage, identify what clinical data will be needed fr any ppulatin reprts. Be sure this data is being discretely ppulated in the EHR. Often, the reprt desired cannt be generated because the data wasn t captured, stred, r retained fr that purpse. There are Page 7 f 30

8 many instances where the HIM department r ther departments maintained lgs f patients; each f these lgs shuld be able t be created and maintained as part f the ppulatin reprts. It will be equally imprtant fr ther members f the implementatin team t visualize the changes in their wrkflw. HIM prfessinals can prvide invaluable insight fr the clinical team in assisting it t cnsider all issues affecting the clinical wrkflw and ging paperless. If the recrd is mved frm the active database t an archival database, check that all f the recrd is retrievable in the same frmat and desn t require special prgramming t retrieve r print the recrd. Be actively invlved in testing the backup. Dn t wait until the system has crashed and needs t be restred t find ut that the backup desn t wrk adequately. When implementing a new electrnic recrd system, dn t frget t have the prject plan include the printing f all reprts. Sme systems are sld as paperless and d nt have reprts develped t be printed ut f the system if necessary. When a new data element is created in the system, make sure that the new infrmatin is viewable and printable. Sme systems take additinal prgramming t get the new data int a viewable r printable frmat. If yu are ging paperless in several different systems (e.g., radilgy, physician rder entry), evaluate hardware needs in each department t ensure that all staff can access the system as apprpriate t their jb functins. Sme systems have licensing limitatins and culd cause access restrictins. Ensure that system updates ccur n the server and d nt require manual interventin n each cmputer r desktp. Imagine having t visit every cmputer r user each time a change is made. Likewise, verify that ne installatin grants applicatin access t all prfiles n that cmputer. References Amatayakul, Margret, et al. Definitin f the Health Recrd fr Legal Purpses. Jurnal f AHIMA 72, n. 9 (2001): 88A H. Dugherty, Michelle. Maintaining a Legally Sund Health Recrd. Jurnal f AHIMA 73, n. 8 (2002). E-HIM Wrk Grup n Health Infrmatin in a Hybrid Envirnment. The Cmplete Medical Recrd in a Hybrid EHR Envirnment Available nline at Fr additinal resurces, seek ut prfessinal peers wrking thrugh the same issues. Review the e- HIM practice briefs and search the FORE Library: HIM Bdy f Knwledge. Jin AHIMA Cmmunities f Practice such as e-him, Enterprise Imaging, and Cmputer-based Patient Recrds. Prepared by Beth Acker, RHIA Debra Adams, RN, RHIA, CCS, CIC Ken Cle Camille Cunningham-West, RHIA Michelle Dugherty, RHIA, CHP Chris Ellitt, MS, RHIA Cathy Flite, M.Ed., RHIA Maryanne Fx, RHIA Rnna Grss, RHIA Susan P. Hansn, MBA, RHIA, FAHIMA Debrah Khn, MPH, RHIA, CHE, CPHIMS Tricia Langenfelder, RHIA Beth Liette, RHIA Mary Ellen Mahney, MS, RHIA Page 8 f 30

9 Carl Ann Quinsey, RHIA, CHPS Dnna J. Rugg, RHIT, CCS Cheryl Servais, MPH, RHIA Mary Staub, RHIA, CHP Anne Tegen, MHA, RHIA, HRM Lydia Washingtn, MS, RHIA, CPHIMS Kathy Wrazidl, RHIA The AHIMA Electrnic Health Recrds Management wrk grup is funded by a grant t the Fundatin f Research and Educatin (FORE) frm Precyse Slutins. Article citatin: AHIMA Wrk Grup n Electrnic Health Recrds Management. "The Strategic Imprtance f Electrnic Health Recrds Management: Checklist fr Transitin t the EHR". Jurnal f AHIMA 75, n.9 (Octber 2004): 80C-E. Cpyright 2004 American Health Infrmatin Management Assciatin. All rights reserved. Page 9 f 30

10 The Strategic Imprtance f Electrnic Health Recrds Management. Appendix A: Issues in Electrnic Health Recrds Management Electrnic health recrds management (EHRM) is the prcess by which electrnic (e.g., digital) health recrds are created r received and preserved fr legal r business purpses. EHRM requires decisin making thrughut the electrnic health recrd's life cycle thrugh the prcessing, distributin, maintenance, strage, and retrieval f the health recrd t its ultimate dispsitin, including archiving r destructin. The scpe f EHRM must include a determinatin f what electrnic health recrds t keep and fr hw lng, the assignments f authrities and respnsibilities, the design and administratin f the prcess, the integrity f the data, and the audit and review f the prcess's perfrmance. Dcument/Recrd Management Recrd Order Paper Systems Hybrid r Transitinal Systems Fully Electrnic Systems Written plicy identifies the reprts that make up each recrd type (e.g., inpatient, emergency rm) and the specific dcument rder in the chart. HIM staff ensure the chart is in the rder specified in the supprting prcedure prir t filing. Written plicies specify which reprts and dcuments make up the legal health recrd as defined by the rganizatin. The plicies identify which reprts are paper and which are electrnic. As the need t print and assemble paper-based recrds diminishes, HIM management needs t transfer r retrain staff t wrk in ther peratinal areas (e.g., assembly clerks might be trained t perfrm dcument preparatin r scanning if imaging has been deplyed). When the EHR is printed, a standardized chart rder must be develped based n the user's needs (e.g., different EHR views may necessitate different assembly rder fr lawyers and patients). Recrd rder may cntinue t be imprtant t HIM nce a ttally electrnic frmat is achieved. If scanning dcuments cntinues t be part f the EHR, the prcessing f the dcuments prir t scanning, indexing, display, string, and destructin will be an essential functin. Frmat and access shuld be defined accrding t the infrmatin system chsen and the user's need fr prtected health infrmatin relative t his r her jb fr bth display and print capabilities. When the EHR must be printed, a standardized chart rder based n the user's needs must be develped (e.g., different EHR views may necessitate different assembly rder fr lawyers and patients). Wrkflw Changes Paper Systems Hybrid r Transitinal Systems Fully Electrnic Systems Written plicies list the reprts required t signify Cnsider electrnic rules and alerts n ROI requirements t allw fr Cnsider electrnic rules and alerts n ROI requirements t allw fr Page 10 f 30

11 the recrd is cmplete and ready fr purpses such as cding, release f infrmatin (ROI), and meeting the rganizatin's legal definitin. HIM staff fllw written prcedures t review each recrd received in the department. Frms inventry is critical, as is frms design fr efficient capture f infrmatin. expanded delegatin f ROI peratinal capabilities and respnsibilities. Develp plicies fr disclsure tracking and auditing capabilities. Determine whether ROI will remain centralized in HIM r be decentralized. Ensure that the rganizatin has care-fully planned EHR cntent and access prir t mving cding r transcriptin functins ff-site(e.g., will cders require nline access t clinical dcumentatin, such as dctrs' prgress ntes?). Frms inventry and design becmes even mre critical at this phase, as efficient prcessing (scanning, indexing, and nline review) is predicated n effective frms management. Define when the recrd is cmplete fr cding purpses (e.g., what reprts will be available t cders and in what frmat, paper r electrnic). expanded delegatin f ROI peratinal capabilities and respnsibilities. Develp plicies fr disclsure tracking and auditing capabilities. Determine whether ROI will remain centralized in HIM r be decentralized. Ensure the rganizatin pssesses apprpriate access t EHR cntent prir t mving cding r transcriptin functins ff-site. Define when the recrd is cmplete fr cding purpses (e.g., must specific reprts be available t cders prir t cding?). Frms management and cntrl are essential s that manual prcessing is avided and the EHR can be legally upheld withut disruptin f "unfficial" frms. Recrd Cmpletin Paper Systems Hybrid r Transitinal Systems Fully Electrnic Systems Written prcedures utline deficiencies t lk fr when reviewing the different recrd types (e.g., IP, ER). Each recrd is reviewed fr presence r absence f reprts requiring necessary signatures. If using an autmated deficiency system, deficiencies are manually entered int the system fr tracking and ntificatin that cmpletin is Written prcedures utline deficiencies t lk fr when reviewing the different recrd types (e.g., IP, ER). Review and cnsider e-signature prcessing capabilities, limitatins, and pprtunities fr electrnic prtins f the EHR.* Determine if the vendr can autmate deficiency analysis. Establish business rules fr viewing the EHR based n an individual's rle and the cmpletin status f a dcument (e.g., shuld ROI staff see Written prcedures utline deficiencies t lk fr when reviewing the different recrd types (e.g., IP, ER). Review and cnsider e-signature prcessing capabilities, limitatins, and pprtunities fr electrnic prtins f the EHR.* Determine if the vendr can autmate deficiency analysis. Establish business rules fr viewing the EHR based n an individual's rle and the cmpletin status f a dcument (e.g., shuld ROI staff see Page 11 f 30

12 necessary. nly cmplete electrnic recrds?). Ensure EHR system capabilities t mnitr and track recrd r dcument cmpletin (e.g., ntificatins t individual clinicians, aggregated management screens and reprts fr HIM) nly cmplete electrnic recrds?). Ensure EHR system capabilities t mnitr and track recrd r dcument cmpletin (e.g., ntificatins t individual clinicians, aggregated management screens and reprts fr HIM) *Cnslidated Health Infrmatics. "Standards Adptin Recmmendatin." Available at Filing Paper Systems Hybrid r Transitinal Systems Fully Electrnic Systems Recrds are filed in flders, and each is assigned a patient-specific number. Organizatinal plicy shuld define the medical recrd numbering system utilized. Plicy defines where and hw recrds are stred. Retentin schedule is included in the plicy. Plicy utlines handling and strage f incmplete recrds, as well as when the recrd is cnsidered cmplete fr permanent filing. Determine what file rm peratins are needed t ensure acceptable prductivity and custmer service levels in a hybrid file rm envirnment (e.g., a cmbinatin f hard-cpy recrds, scanned recrds, and infrmatin in a data repsitry). Cnsideratins shuld include: Functins and tasks Hurs f peratin After-hurs access and backup Staffing needs Recrd cntrl Filing/indexing Retentin, purging, archiving Review file rm staffing and need t reduce r redefine staff as the recrd becmes fully electrnic. Determine whether any f the paper recrd will be cnverted t electrnic frmat r will paper recrds be phased ut ver time as a result f retentin and purging plicies. Establish plicies and prcedures t utline the management f remaining paper recrds. Lcking the Recrd Paper Systems Hybrid r Transitinal Systems Fully Electrnic Systems Written plicies and prcedures define when the recrd is cmplete and permanently filed (e.g., all lse reprts filed, deficiencies cmplete, cding is dne) Written plicies and prcedures define what part f the recrd is kept as paper and what is electrnic. Plicy als defines when bth paper and electrnic prtins f a hybrid recrd are cnsidered cmplete (e.g., n additinal HIM prcessing is required, all reprts are cmplete). Written plicies and prcedures define when a recrd is cnsidered cmplete (e.g., n additinal HIM prcessing is required, all reprts are cmplete). Plicy must indicate at what pint electrnic dcuments are lcked and available as read-nly. Any subsequent additins, changes, r deletins are handled as addendums t the recrd. Sftware must have the ability t insert a recrd dcument in Page 12 f 30