Nicohwilliam

Assignment 2: answer real world case 3.1 questions; at least one page; cite textbook below and or other sources; please see text book below

Real-World Case 3.1

General Hospital knew they had issues with duplicate health records and needed to clean up the master patient index (MPI) before the implementation date for the electronic health record (EHR) to get the best results. A consulting firm was hired, and a review of the data confirmed this problem when they identified over 3,000 potential duplicate health records issued over the past five years. The hospital started the MPI cleanup process by educating their patient registration staff on proper search strategies, questions to ask the patient, the importance of a unit health record, and other related topics. This education was an important first step so that additional duplicate health records would not be assigned while the cleanup process was going on. Once the training was complete, the consulting firm began cleaning up the MPI. The consultants reviewed the potential duplicate health records and merged the health records where appropriate. They ensured the health records were merged in other information systems used throughout the healthcare organization. They provided documentation to General Hospital showing which health records were and were not duplicates based on their review. They also provided statistics on which admission clerks created duplicate health records, and the departments (admissions, emergency department, outpatient services and others) that created the duplicates.

1. What would you include in the training?  

The training could include a number of topics including:  

· Impact of duplicates on patient care  

· Questions to ask patients during registration  

· Use of algorithms  

· Process to correct duplicates including time required and costs  

   

2. In the same situation, would you have hired a consultant?  

   

   

3.         Why did the healthcare organization find itself in this situation?

Health Information Management Technology,

An Applied Approach

Nanette Sayles, Leslie Gordon

Copyright ©2020 by the American Health Information Management Association. All rights reserved. Except as permitted under the Copyright Act of 1976, no part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, photocopying, recording, or otherwise, without the prior written permission of AHIMA, 233 North Michigan Avenue, 21st Floor, Chicago, Illinois 60601-5809 (http://www.ahima.org/reprint).

ISBN: 978-1-58426-720-1

AHIMA Product No.: AB103118

Chapter 3 HITT 1301

Health Information Functions, Purpose, and Users

The health record contains information relating to the physical or mental health or condition of an ­individual, as made by or on behalf of a health professional in connection with the care ascribed that individual. In other words, the health record contains the who, what, where, when, why, and how of patient care and is used for many reasons and by many people. When discussing these usages and users, it is important to understand the difference between three terms—data, information, and knowledge. The terms data and information are often used interchangeably but they are distinctly different. Data are raw facts and figures such as Hospital A discharged 560 patients last month. Information is data that have been turned into something meaningful such as Hospital A discharged 560 patients last month, which was up 10 percent from the prior month and 20 percent from this time last year. Knowledge is the information, understanding, and experience that give individuals the power to make informed decisions. For ­example, ­investigation identified that the increase in patients was primarily due to an increase in obstetrics patients. This increase in obstetrics patients is why the healthcare organization decided to investigate ways to improve its obstetric services.

Purposes of the Health Record

The uses of a health record can be divided into primary and secondary purposes. The primary purposes are those for which the health record is developed and used—patient care. The secondary purposes are those where the health record is used for healthcare purposes not directly related to patient care.

Primary Purposes

The primary purposes of the health record are ­related to providing care to the patient. Patient care includes the direct care provided and the day-to-day business of the healthcare organization. These usages can be categorized in the following ways:

· Patient care. One of the most important uses of the health record for patient care is the documentation of the care provided by physicians, nurses, and allied health professionals such as physical therapists and dietitians. This documentation serves as a communication tool between these healthcare professionals, as discussed in chapter 2, Healthcare Delivery Systems, and may contain treatments and the patient’s response to the treatment. For more information on health record documentation, see chapter 4, Health Record Content and Documentation.

· Management of patient care. The health record is an important part of managing patient care services performed at the healthcare organization. The health record is used to develop patient care standards; conduct research at the local, state, and national levels; and evaluate the quality of care ­provided. For more on quality, see chapter 18, ­Performance Improvement.

· Administrative purposes. The health record is used for administrative purposes including billing for services provided, making decisions about the future of the healthcare organization, monitoring the fiscal health of the organization, and scheduling staffing. Many administrative purposes are discussed in ­detail in chapter 13, Research and Data Analysis, chapter 14, Healthcare Statistics, chapter 15, Revenue Management and Reimbursement, and chapter 18.

Secondary Purposes

Healthcare is a sophisticated industry and information from the health record is used for many purposes not related specifically to patient care. These secondary purposes include the following:

· Education of healthcare professionals. Health records are used by medical, nursing, and other allied health professionals including health information management (HIM) to teach present and future healthcare providers how to document care provided, and how to manage the healthcare information. See chapter 20, Human Resources Management, for more on training.

· Legal, accreditation, and policy development. The health record is used to protect the healthcare organization from medical ­malpractice and other lawsuits, to monitor compliance with laws and regulations, and to adhere to accreditation standards. Information from the health record is also used at the national level to determine where funding will be allocated, as well as the direction the healthcare industry should take. For additional information on how the record is used for legal purposes, see chapter 8, Health Law, chapter 9, Data Privacy and Confidentiality, and chapter 10, Data Security.

· Public health and research. Data in the health record are aggregated and turned into information that is used at the national level to establish best practices of patient care, conduct research on new medications and technologies, and study patient outcomes. New diseases are continuously identified while current ones evolve, sometimes making them resistant to traditional treatment. The information from the health record is used to determine what traditional and nontraditional treatments are effective for these new diseases and conditions. Registries are covered in chapter 7, Secondary Data Sources. Local health departments use health information to identify outbreaks in diseases early so the source of the disease can be managed, and epidemics can be managed or prevented. For additional information regarding public health and research usage, see chapter 14, Healthcare Statistics.

Formats of the Health Record

To understand how the health record is used, it is important to understand the three types of health records: paper, electronic, and hybrid. The paper health record is completely available in paper media. Some portions of it may have been created electronically, like lab results, but the lab results are printed and filed in the paper health record. The electronic health record (EHR) is a digital record of an individual’s health-related ­information that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization. The hybrid health record, also known as hybrid record, is a combination of the paper health record and the EHR. In the hybrid health record, some documents are stored in the paper health record while others are stored in the EHR. The electronic documents may or may not be printed and stored in the paper health record. These three types of health records are discussed in more detail later in this chapter.

Users of the Health Record

Healthcare providers are the primary users of the health record; however, others use the health record to manage the healthcare organization and the healthcare industry. Some users of the health record access and use the health record directly while others use data or information that has been aggregated from multiple health records. Aggregate data are data that have been extracted from individual health records and combined to form deidentified information about groups of patients that can be compared and analyzed. For example, aggregate data can be used to determine survival rates for various kinds of cancer or to determine if a new drug is safe. Deidentification is the removal of all data elements that can identify the patient.

Individual Users

Individual users are those who depend on the health record to complete their jobs. The way the health record is used varies by individual user. For example, nurses use physician orders to know how to care for the patient. The following are ­descriptions of these individual users:

· Patient care providers. Patient care providers include physicians, nurses, and other allied health professionals who rely on information from the health record to make decisions about the care provided to the patient and for documentation of care. Allied health professionals include respiratory therapists, nutritionists, physical therapists, and many more. (Chapter 2, Healthcare Delivery Systems, covers allied health professionals in more detail.)

· Patient care managers and support staff. Patient care managers evaluate the services provided by their employees. As care is documented in the health record, it becomes a key resource in their evaluation of the quality of care provided. The managers look for patterns and trends to recommend changes to the process to improve outcomes and efficiency of the care provided. Support staff gathers information for the patient care managers to use.

· Coding and billing staff. Documentation in the health record is the basis for reimbursement, or payment, for the care provided. The coding staff at the healthcare organization must read the entire health record and assign the appropriate diagnoses and procedure codes for treatment received during the encounter. The billing staff obtains the codes from the coders and submits the bill to the insurance company. (Chapter 15, Revenue Management and Reimbursement, covers reimbursement in more detail.)

· Patients. Patients are informed consumers of their healthcare. As informed consumers, patients may obtain access to and be informed about their health record by obtaining a copy of their health record, accessing a patient portal, or maintaining a personal health record. Personal health records are discussed later in this chapter. (Chapter 9, Data Privacy and Confidentiality, covers patient rights and the health record in more detail.)

· Employers. Employers may use health records when processing health insurance claims and in managing wellness programs. Employers may also use the health record to determine when employees are well enough to return to work after an injury or illness, although this is generally limited to a note from the physician giving his or her approval. When an employee claims disability due to a work-related incident, it is the information found in the health record that supports or refutes the claim.

· Lawyers. Lawyers may need access to support a client (the patient) for life insurance claims and lawsuits such as those related to motor vehicle crashes, disability, and such. The lawyer must obtain consent from the patient to access the patient’s health information. To protect themselves from medical malpractice and other lawsuits, healthcare organizations may grant lawyers access to patient records.

· Law enforcement officials. Law enforcement officials need access to health record documentation to investigate gunshot wounds and other injuries resulting from a crime. They also may access documentation for information that will help protect the security of the country.

· Healthcare researchers and clinical investigators. Healthcare researchers use health records to study the safety and efficacy of drugs or the value of care provided. The researcher’s aggregate data and information based on these findings are used to approve new treatments and to stop unsafe treatments. How the health record is used in research is covered in more detail in chapter 14, Healthcare Statistics.

· Government policy makers. The health record may be used to develop and evaluate current and future laws, regulations, and standards related to healthcare. The data collected can help determine best practices, gaps in current legislation, and other issues that need to be addressed to improve care and prevent fraud.

Institutional Users

Institutional users are organizations that need access to health records to accomplish their mission. Institutional users include healthcare organizations, third-party payers, medical review organizations, research organizations, educational organizations, accreditation organizations, government licensing agencies, and policy-making bodies.

· Healthcare organizations. Healthcare organizations—including hospitals, physician offices, home health agencies, and others—use the health record to provide care, submit claims for reimbursement, and evaluate the quality of care provided.

· Third-party payers. Third-party payers are organizations responsible for the reimbursement of healthcare services through an insurance program. These insurance programs include commercial insurance, managed care organizations, government insurance programs, accountable care organizations, as well as self-insured employers. The health record is used to justify the care provided and therefore the reimbursement. For additional information, refer to chapter 15, Revenue Management and Reimbursement.

· Medical review organizations. Medical review organizations evaluate the quality and appropriateness of the care provided to the patient. Medicare hires organizations known as quality improvement organizations to determine if the care provided to the patient was medically necessary. See chapter 18, Performance Improvement, for more information on quality improvement organizations.

· Research organizations. Research organizations conduct medical research and include state disease registries such as the cancer registry, research centers, and others who explore diseases and their treatment.

· Educational organizations. Colleges and universities train healthcare professionals. The students in these programs use the health records as case studies as a part of the educational program.

· Accreditation organizations. To be granted and maintain accreditation, a healthcare organization must show compliance with the accrediting body standards. This frequently requires review of the health record to determine compliance with documentation and patient care standards. For example, the accreditation organization may require the history and physical (refer to chapter 4, Health Record Content and Documentation) to be completed within 24 hours of admission. To learn more about accreditation, see chapter 8, Health Law.

· Government licensing agencies. Government agencies at the local, state, and federal level review the health record to ensure compliance with state licensing requirements and to verify compliance with standards that enable the healthcare organization to receive federal funding. A more detailed discussion on licensing is also included in chapter 8, Health Law.

· Policy-making bodies. The data submitted for healthcare claims to governmental databases and other sources are analyzed and utilized for decision-making related to healthcare programs. For example, the Centers for Medicare and Medicaid Services (CMS) utilize a wide range of data to revise reimbursement systems each year.

Overview of HIM Functions

The HIM department performs many functions to support patient care and the healthcare organization. The functions focus on ensuring the quality, security, and availability of the health record. Some functions are performed in the HIM department, while others may be in their own ­department or outsourced. Outsourcing is the hiring of an individual or a company external to an organization to perform a function either on-site or off-site. Typical HIM functions include the following:

· Medical transcription and voice recognition

· Disclosure of health information

· Clinical coding and reimbursement

· Record storage and retrieval (paper and electronic)

· Statistics and research

· Master patient index

· Record storage and retrieval (paper and electronic)

· Record processing

· Registries (cancer, trauma, birth defects, and more) Birth and death certificate completion

The HIM department operates in conjunction with other departments to support and enhance their services including patient care, information governance, quality management, billing, and patient registration.

Medical Transcription and Voice Recognition

Medical transcription, the process of deciphering and typing medical dictation, may be a part of the HIM department or it may be a separate centralized department where all transcription services are performed. Transcription services may also be outsourced to another company. In that case, there should be a liaison between the HIM department and the transcription company. This liaison would work with physicians, monitor turnaround time, monitor the quality of the work, and more. Commonly transcribed reports include history and physical, discharge summary, pathology reports, procedure reports (such as colonoscopy and cardiac catheterization), and radiology reports. See chapter 4, Health Record Content and Documentation, for a description of these reports.

The transcription manager is responsible for monitoring the quality of the documents and services performed. The transcription supervisor should review a sample of the documents typed to ensure that proper formatting was used, there were no typographical or other errors, and it was transcribed in a timely manner. The date dictated and the date transcribed should be recorded on the document. The expected turnaround time is determined by the healthcare organization and may vary by document. For example, a radiology report may be transcribed within 24 hours and a discharge summary within three days of dictation.

Today, healthcare organizations may use speech recognition to go directly from dictation to a typed document. There are two strategies to be considered with speech recognition. Front-end speech recognition occurs when physicians review and edit the document directly upon dictation and then can sign it immediately. The document is available quickly with this strategy. The other strategy is back-end speech recognition. In this strategy, the transcriptionists become editors, making corrections to the document rather than typing it. Because they review and edit the document after dictation, the physician cannot sign the document until a later time. The advantage is that the physician can focus on patient care rather than correcting any issues in the document.

Disclosure of Health Information

One of the responsibilities of the HIM department is disclosure of health information. Disclosure of health information is the process of disclosing patient-identifiable information from the health record to another party. The HIM department receives a request for access to patient information, ensures that the request is appropriate for release, and then submits the information for use in patient care, insurance claims, legal claims, or other purpose. Disclosure of health information can be performed internally or can be outsourced to a disclosure of health information company. For more information on disclosure of health information and privacy requirements, see chapter 9, Data Privacy and Confidentiality.

The disclosure of health information supervisor is responsible for ensuring policies and procedures are followed, requests are processed in a timely manner, and the staff meets their productivity requirements. Quality control for the disclosure of health information function includes ensuring the health records are available first and foremost for patient care. It also includes ensuring the requested documents and only the requested documents are released or disclosed.

The supervisor is responsible for ensuring turnaround times are met. Turnaround time is the time between receipt of request and when the information is sent to the requester. The disclosure of health information system discussed later in this chapter can report this statistic.

The disclosure of health information staff is responsible for documenting to whom information is released, when it was released, and specifically what was released. This is known as an Accounting of Disclosure Log. This includes specific document(s) and the dates of service. A copy of the formal request for copies of patient information must be retained by the HIM department.

Clinical Coding and Reimbursement

Clinical coding, or assigning codes to represent diagnoses and procedures, is a key responsibility of the HIM department. Several coding systems can be used. During the coding process, data are abstracted into the information system. ­Abstracting can be either the process of extracting information from a document to create a brief summary of a patient’s illness, treatment, and outcome, or the process of extracting elements of data from a source document or database and entering them into an automated system. The amount of data abstracted for coding purposes varies by healthcare organization but includes data such as date of surgery, surgeon, and disposition of patient upon discharge (went home, transferred to another hospital, and so forth). The codes are included on the bill and are used to determine reimbursement that the healthcare organization will receive. The coding supervisor must ensure the quality of code assignment and the timeliness of the coding process. If the coding process gets behind, the encounters cannot be billed, thus ensuring that reimbursement for patient care is delayed. For more information on coding, refer to chapter 15, Revenue Management and Reimbursement.

Record Storage and Retrieval Functions

A healthcare organization cannot move quickly from a paper-based record to an electronic record. The transition to the EHR can take years and often involves a hybrid record—part of the health record on paper and part of it electronic. During this time, some functions will be handled as described in the paper-based record environment while others may be handled electronically. As the percentage of the record digitized increases, more of the functions will be as described in the electronic record environment.

A common information system that is used during this transition period is the document management system (DMS). The DMS scans the paper record and stores it digitally. The user has the benefits of immediate access but unfortunately the user is not able to manipulate the data as the document is stored as a picture, not data. One of the advantages of a DMS is the ability to control the workflow electronically. The workflow is not limited to the HIM department but can be automatically routed to other users throughout the healthcare organization.

During the period of transition to an EHR, it is difficult to identify the legal health record as some of it is paper, some is electronic (and may be in a multitude of information systems), and some documents are created electronically but may be printed and stored in the paper health record. (Chapter 4, Health Record Content and Documentation, covers the legal health record in more detail.) This period is also challenging as the HIM department must manage both the paper and the electronic documents.

Master Patient Index

The master patient index (MPI) is the permanent record of all patients treated at a healthcare organization. It is used by the HIM department to look up patient demographics, dates of care, the patient’s health record number, and other data. Demographics, also known as demographic data, are basic information about the patient such as their name, address, date of birth, and insurance information. The MPI is an important element of a numeric filing system (discussed later in this chapter) as it allows the user to look up the patient health record number so the record can be located. When a healthcare enterprise has more than one healthcare organization (such as ­hospital and ambulatory clinic) and the patient is seen at two or more places, the enterprise master ­patient index (EMPI) links the patient’s information at the different healthcare facilities. The recommended core data elements for the EMPI are the following:

· Internal patient identification

· Person name

· Date of birth

· Gender

· Race

· Ethnicity

· Address

· Telephone number

· Alias, previous, or maiden names

· Social security number

· Facility identification

· Universal patient identifier

· Account or visit number

· Admission or visit number

· Admission, encounter, or visit data

· Discharge or departure date

· Encounter service type

· Encounter primary physician

· Patient disposition (AHIMA 2010)

Before computerization, the MPI was maintained on index cards; now the MPI is generally electronic, which allows for alphabetic and phonetic search capabilities, as well as the ability to search numerous data elements such as patient name, health record number, and billing number. A phonetic search retrieves names that sound the same; for example, Burgur, Burger, Berger, and Burgher. Figure 3.1 provides an example of an input screen for an electronic MPI system.

The health record number is created by the MPI and the numbers are issued in sequential numeric order. For example, Ms. Smith is admitted to the healthcare organization at 4:00 p.m. and is issued the health record number of 156876. When Ms. Jones, the next new patient, is admitted at 4:06 p.m., she is issued the health record number of 156877.

Unfortunately, there are data quality issues that result from improper issuance of health record numbers. Typographical errors, outdated demographic information, and other data quality issues are always present in the MPI. For example, patients change their name, identify themselves by their nickname, move, or change phone numbers. Some errors occur through data entry; for example, entering the birthday of January 1, instead of January 11. The erroneous information is then shared with other information systems, exacerbating the problem. It takes a lot of time to identify and correct the erroneous information. Some of the more common problems include duplicates, overlays, and overlaps.

When the patient is registered in the admissions department, previous MPI information may not be retrieved if the clerk does not conduct a thorough search for the patient or if the patient gives a different name. For example, the patient may give her new married name rather than her maiden name. The patient may also give a nickname, such as Bob, rather than his legal name, Robert. This results in a duplicate health record number being issued. A duplicate health record results when the patient has two or more health record numbers issued. The patient’s health information becomes fragmented with some information under the first number and the remainder under the second number. When this happens, duplicate laboratory testing may occur, causing unnecessary expenses, poor decisions such as misdiagnoses or unnecessary tests, and the healthcare organization’s increased legal risk with the potential for medical malpractice.

Another problem with the question of the quality of the MPI is an overlay. With an overlay, a patient is erroneously assigned another person’s health record number. When this happens, patient information from both patients becomes commingled and care providers may make medical decisions based on erroneous information, increasing the legal risks to the healthcare organization and quality of care risks to the patient. For example, a patient with the name Jeffery Johnson, date of birth January 1, 1962, may be mistaken for Jeffery Johnson, date of birth January 1, 1957. One of the more common reasons for this is an error in selecting the correct patient by the hospital staff.

A third issue is an overlap, or when a patient has more than one health record number at different locations within an enterprise or healthcare organization. This frequently becomes an issue when healthcare organizations merge or create an EMPI.

A healthcare organization must work to protect the integrity of the data in the MPI. Most errors are human. The clerk may transpose numbers, make typographical errors or use poor search strategies that fail to find the patient in the information system, or the patient may give inaccurate information.

All healthcare organizations must have processes in place to maintain and correct the MPI against the quality issues of duplicates, overlays, and overlaps on a continuous basis. Algorithms are used to match patients so the patient information can be merged. There are three types of matching algorithms typically found in the MPI. The first, a deterministic algorithm, requires exact matches in data elements such as the patient name, date of birth, and social security number. The second, a probabilistic algorithm, uses mathematical probabilities to determine the possibility that two patients are the same. The third, a rules-based algorithm, assigns weights to specific data elements and uses those weights to compare one record to another (AHIMA 2010).

This clean-up process is ongoing. There should be a formal process to help prevent and identify potential duplicates. Staff should be educated on the impact of errors in the MPI. When duplicates, overlays, and overlaps are identified, the department managers need to be notified so they can address the problem with the staff making the errors.

Record Storage and Retrieval Functions in a Paper Environment

While the EHR is becoming more prevalent, the existing paper records have not disappeared. While HIM professionals operate in the EHR environment, the paper records must still be managed. The following sections address the HIM processes for the creation, storage, and maintenance of ­paper-based records.

The HIM department is responsible for the storage and retrieval of the paper-based record. Policies and procedures should be in place to ensure access to the health records for authorized users but to prevent access for unauthorized users. In a paper-based record, the documentation is typically stored alphabetically or numerically in a special file folder. Healthcare organizations may also file their paper-based records off-site, on microfilm, or digitally as scanned documents.

In a paper-based record filing system, the folders containing the health records are stored in shelving units or in filing cabinets based on the health record number or patient name. The filing systems used are the following alphabetic filing systems, numeric filing systems, and alphanumeric filing systems.

· Alphabetic Filing System In the alphabetic filing system, health records are filed in alphabetic order. This system works well with a small volume of health records such as in a physician practice. Employees are comfortable with it and the filing system is easy to create and use. A disadvantage is that there is no unique identifier as patients can have the same name. Another problem is the alphabetic filing system does not expand evenly. Statistically almost half of the files fall under the letters B, C, H, M, S, and W. Figure 3.2 contains rules for alphabetic filing.

· Numeric Filing Systems In a numeric filing system, the health records are filed by the health record number. The MPI is consulted to identify the health record number and then the number is used to locate the health record. This may seem like more work than the alphabetic system but there are many advantages to the numeric filing system. The most common types of numeric filing systems are the following:

● The straight numeric filing system files the records in straight numeric order based on the health record number. This filing system is easy to teach to new employees; however, the most ­active area in the files is the higher numbers, which are the most current files, ­making it difficult to manage. Management problems include the higher number of department staff in one section of the file room and the space required by the health records may exceed the amount available.

● The terminal-digit filing system may sound backward, but it is typically considered the most efficient of the numeric filing systems in part because it distributes health records evenly throughout the filing units. It is also effective for healthcare facilities with a heavy record volume. The health records are filed by the last two digits, called the terminal digits, then the middle two digits, known as the secondary unit. The health records are then filed by the first two or three numbers, known as the tertiary units. See figure 3.3 for an example.

· Alphanumeric Filing System As the name alphanumeric filing system indicates, both alphabetic and numeric characters are used to sort health records in this system. The first two letters of the patient’s last name are followed by a unique numeric identifier such as SA2567. This filing system is appropriate for small healthcare facilities. Like numeric systems, alphanumeric filing systems require an MPI.

Paper health records are frequently filed in a centralized unit filing system. In a centralized unit filing system, any patient encounters are filed together in a single location. For example, a patient may be seen in radiology for a mammogram and in the laboratory for a urinalysis. These test results will be filed together. This type of filing system is usually associated with the unit numbering system; the unique identifiers can be alphabetic, alphanumeric, or numeric depending on the needs of the healthcare organization.

Storage Systems for Paper-Based Records Several options are available for storing paper records including filing cabinets, shelving units, microfilm, off-site storage, and image-based storage. The storage choice for health records depends on the needs and storage capacity of the healthcare organization.

Vertical and lateral filing cabinets, open shelves, or compressible filing units can all be used for storage of records. Vertical and lateral filing cabinets are seen in most office settings and usually contain two or four drawers. These small filing cabinets are only appropriate for low-volume storage as it is challenging to quickly access health records from the drawers.

Typically, an HIM department uses open shelving units that resemble bookcases and can store large volumes of files that are easy to view and access. Multiple shelves separated by aisles large enough for a person to walk through to access the files can be used. A common variation is compressible filing units, where there is not an aisle between each shelving unit but instead one or two aisles while the rest of the units are collapsed together. These shelving units move and the aisles open and close as needed. The units are on tracks, which allow the units to be moved to open up the aisle.

Files of patients who have not been at the healthcare organization for a specified period, such as two years, may be purged or removed from the active filing area. The time period and frequency of purging depends on the space available, patient readmission rate, and the need for access to the health record. For more information on retention and destruction, see chapter 9, Data Privacy and Confidentiality.

An important role of the HIM professional is to determine the space requirements needed to store the paper health record by evaluating the volume indicators such as number of discharges, size of records, and the capacity of the storage units. For example, the space needed can be estimated with the following information:

Shelving unit shelf width = 36 inches

Number of shelves per unit = 8 shelves

Average record thickness = ½ inch

Average annual inpatient discharges = 10,200

The following demonstrates how these statistics are used to estimate the number of shelving units to store one year of health records.

1. Determine the linear inch capacity of each shelving unit.

36 inches per shelf x 8 shelves per unit = 288 inches per shelving unit

2. Determine the linear filing inches needed for the volume of records.

10,200 average annual inpatient discharges x ½ inch average record thickness = 5,100 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.

5,100/288 = 17.7 = 18 shelving units

Since it is impossible to purchase a part of a shelving unit, the number of shelving units required should always be rounded up to a whole number. This example only included inpatient discharges for simplicity; however, outpatient health records would also have to be considered.

In vertical and lateral filing cabinets, open shelves, or compressible filing units, file folders are used to hold paper health records. File folders used for health records are usually purchased in one of two standard weights or thicknesses—11 points and 14 points—although the weight may be as much as 20 points. The higher the points, the more durable the file folder. The amount of filing and retrieval activity will impact the decision. Typically, side tabs are used for health records, but top tabs may be used in lateral shelving units. Two-pronged record fasteners should be placed at the top or sides of the file folder to hold the health record forms in place.

File folders should be color coded for easy filing and retrieval. For example, the tab on the file folder has a label that displays a single digit of the health record number in a specific color. This makes it easy to identify misfiled records. For example, a yellow label would stand out in a row of green and red. Typically, the file folders are purchased with the color-coding already applied, but labels can be applied manually.

Paper health records require a great deal of space. One way to reduce the amount of space required is to microfilm the health record, which is a ­photographic process that reduces an original paper document into a small static image on film. Microfilm has been used for decades by healthcare facilities and works well for inactive or infrequently used health records. A photo image is taken of each page of the health record and stored as a small negative. A microfilm viewer is required to read the image. The following are the different formats:

· Roll microfilm. The microfilm images are stored on a long roll of film. Each roll can store thousands of images for hundreds of patients. The major problem with this format is that patient encounters can be stored on multiple rolls, making retrieval difficult.

· Jacket microfilm. A roll of microfilm is cut and inserted into four-by-six-inch jackets with sleeves. Multiple jackets containing all episodes of care that have been microfilmed can be filed together to maintain the unit-record. The same type of filing systems that apply to paper records can be used.

· Microfiche. This format is a copy of the jacket microfilm. Microfiche is the same size as the microfilm jacket. Some facilities use microfiche rather than allow the original jacket microfilm outside of the HIM department (for example, microfiche would be sent to the nursing unit for patient care).

Inactive records can be stored off-site and copied on microfilm. The healthcare organization would define when a health record becomes inactive. The off-site location may be under the control of the healthcare organization or a commercial company that stores and retrieves the organization’s health records for a fee. The healthcare organization must meet privacy and security regulations in terms of storage of health records. The vendor must be able to protect the health records from fire, pests, burglary, and other hazards. The commercial vendor must be able to return the records to the healthcare organization within a predetermined time. The health records can be faxed, scanned, and emailed, or hand-delivered to the healthcare organization.

Image-based storage is used when the document is scanned and storing it digitally on hard drives, CD, or another storage media. The file ­formats also vary but are typically picture file formats such as .tif or .jpg. The advantage of image-based storage over microfilm is that each document can be indexed or identified by patient or document type. The image itself cannot be searched but the indexed information is used to retrieve patient information. Retrieval of the images with a few keystrokes is a much quicker method than microfilm retrieval.

Retrieval and Tracking Systems for Paper-Based Records? Health records must be accessible to authorized users. A common way of tracking the location of a health record is the outguide. The outguide identifies where the health record is located and when it was removed. It is generally made of colored vinyl with two plastic pockets and it is placed in the shelving unit where the health record should be. The outguide is approximately the size of the health record. The larger plastic pocket can hold documentation that needs to be filed in the health record, known as loose material, which includes dictated reports, reports not filed on the nursing unit, and such. The small pocket can be used to hold a slip of paper that tells where the record has been moved to and when it was checked out.

Traditionally, when a patient care area or other department in the healthcare organization needs a health record, they submit a requisition, or request, for the health record. The requisition tells the HIM department the name, health record number, date of request, name of requester, and where the health record needs to be delivered. The requisition can be handwritten or be generated by an information system.

Today, automated systems frequently create the requisition and replace the outguide. In an automated chart tracking system, the computer keeps up with the location of the health record by “checking out” the health record to the nursing unit or other location. Because of this, an outguide is not needed to record the location of the health record but may still be used to hold the documents to be filed.

Record Processing of Paper-Based Records Record processing ensures health records are ­organized and meet standards. These functions help ensure the accessibility and completeness of the health record. When the quality of the health record is not maintained, patient care suffers due to missing, inaccurate, or incomplete information and it also impacts billing, research, and other purposes. Record processing includes the following processes:

· Admission and Discharge Record Reconciliation for Paper-Based Records When a patient is admitted to the healthcare organization, a search of the MPI is performed to identify if the patient has been at the healthcare organization before. If so, then the paper health record(s) from the previous encounters will be made available for patient care. Once the patient is discharged from the healthcare organization, the health record is taken to the HIM department for processing. The first task is to ensure all health records have been received. This process is known as record reconciliation.

· Record Assembly Function for Paper-Based Records Assembly is the process of ensuring each page in the health record is organized in a standardized format, which varies by healthcare organization. During the assembly process each page should be reviewed to ensure all the pages belong to the same patient and same encounter.

· Analysis for Paper-Based Records Analysis, or review, of the health record is performed by HIM department personnel to determine the completeness of the health record. Two types of analysis should be performed—qualitative and quantitative.

Qualitative analysis is monitoring the quality of the documentation. This is a collaborative effort among the HIM department, risk management, healthcare providers, and others. While the physicians must review the quality of physician documentation, nurses review nurse documentation, and so forth, HIM professionals can review legibility, timeliness of documentation, use of approved abbreviations, and other documentation standards.

Quantitative analysis is a review of the health record to determine if there are any missing ­reports, forms, or signatures. This analysis can be performed by concurrent review—in an ongoing manner while the patient is still in the healthcare organization. It can also be reviewed after discharge from the healthcare organization, known as retrospective review. The review involves the following:

· All forms and reports contain correct patient identification (name, health record number, encounter number, and date of service)

· All forms and reports are present

· Reports requiring signatures are signed

The healthcare organization would base their review on accreditation standards, state licensure, and other standards. When a document or signature is missing, a deficiency slip is created. The deficiency slip identifies the pertinent document and what needs to be done (dictated, completed, and signed), and is often created by a computer system. An example of a deficiency slip is shown in figure 3.4.

When a deficiency is identified in the health record, it must be corrected. This may require locating a missing document or asking the physician or other healthcare provider to either sign or complete a document. The specific analysis performed depends on the medical staff bylaws, rules, and regulations, as well as state licensing and accreditation requirements.

Monitoring Completion of Paper-Based Records Physicians and other practitioners are notified when they have incomplete health records requiring their attention. They usually come to the HIM department to complete the necessary documentation in the health record. The health records are then reanalyzed to ensure everything has been completed. If no deficiencies are identified, the deficiency slip is removed, and the health record is filed away in the permanent file. If a health record remains incomplete for a specified number of days as defined in the medical staff rules and regulations, the record is considered a delinquent ­record. The specific number of days varies by healthcare organization but is generally 15 to 30 days.

Handling Corrections and Addendums in Paper-Based Records Occasionally, health records must be corrected, amended, or deleted. There are a number of reasons for this. Information may be written in the wrong patient’s health record, information may have been omitted, or an error may have been made in documentation. Policies must be in place to ensure the integrity of the health record.

Corrections to the health record should be made by drawing a single line through the erroneous information and writing the word “error” above the mistake. The practitioner should sign, date, and time the correction. An addendum is additional information provided in the health record. The addendum should be dated the day it was written—not the date it is referencing. It should be signed, and the time of entry should be recorded. An amendment is a clarification made to healthcare documentation after the original document has been signed. It should be dated, timed, and signed.

Forms Design, Development, and Control for Paper-Based Records Forms should be designed using appropriate form design principles that will enhance the documentation on the form. The form must meet the needs of the end user, which means it should be easy to use and include all necessary data.

The purpose of the form should be identified before development of the form begins to ensure the appropriate data are included; and the form should not duplicate one that is already in use. ­Users should be involved in development of the form to ensure their needs are met. Effective form design principles include the following:

· All forms should contain a unique identifying number for positive identification and 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 healthcare organization’s name and logo should appear on each page of the form, preferably in the same location on each.

· 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 the information is entered consistently.

· Optical character reader codes and bar codes 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.

· Form colors should be black ink on white paper. If color coding is desired, a strip of color along one margin is the best option.

· 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 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 (AHIMA 1997).

When a document management system is used, form design is critical as the color in both the paper and the ink can negatively impact the quality of the image and should be eliminated or reduced. Forms that will be scanned should have a bar code imprinted on them allowing the automatic indexing into the health record.

Every healthcare organization should have a clinical forms committee to establish standards for design and to approve new and revised forms. The committee should also have oversight of computer screens and other data capture tools. The committee should be comprised of users of health information and include representatives from the following areas:

· HIM

· Medical staff

· Nursing staff

· Purchasing

· Information services

· Performance improvement

· Support or ancillary departments

· Forms vendor representatives

Representatives from the area that will use the form should attend the committee meeting to explain the form and the need for it.

Without oversight the number of forms can become overwhelming to manage and there can be duplication. A forms control program includes the following:

· Establishing standards. Written standards and guidelines should ensure that effective forms design principles, as previously discussed, are used. These standards should be recorded in a forms manual. Standards are fixed rules that must be followed. A guideline provides general direction about the design of the form.

· Establishing a number and tracking system. As stated earlier, a unique number should be assigned to each form. There should be a master form index and a copy of all forms should be maintained. The master form index should include the title, number, origination date, revision dates, purpose, and legal requirements.

· Establishing a testing and evaluation plan. New and revised forms should be tested prior to their implementation to ensure data elements are not missing and that there is enough space to write.

· Checking the quality of new forms. A process should be in place to guarantee that the printed forms were printed correctly.

· Systematizing storage, inventory, and distribution. There must be a process to store and distribute the forms where and when they are needed.

Establishing a forms database. An electronic ­database should be used to store and ­facilitate updating forms.

Quality Control Functions in Paper-Based Systems: There must be processes in place to safeguard the quality of analysis and forms design. Each function should have its own acceptable level of performance and monitoring should be performed to confirm the standards are met. If not, corrective actions should be taken. See chapter 18, Performance Improvement, for more on quality ­improvement.

Several components of storage and retrieval are monitored. Managers monitor misfiles, timeliness of storage and retrieval to calculate filing accuracy, and timeliness rates. Examples of standards include the following:

· An average of 50 health 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 health record or the outguide pocket within 24 hours of receipt in the HIM department

To complete health records in a paper media, the physician must come to the HIM department to dictate, sign, or otherwise complete the health record. If health records are unavailable to the physician when he or she tries to complete the health record, the completion of the health record is delayed. The manager monitors the number of health records not available to physicians, usually weekly.

Record Storage and Retrieval in an Electronic Environment

The functions of the HIM department have changed dramatically with the introduction of the EHR. The EHR is an electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization. Because of the changes, the paper health record is gradually being eliminated.

Record Filing and Tracking of EHRs Filing of health records is significantly reduced or even eliminated in the EHR environment. As more data are captured directly into the EHR, there is no need for paper or the storage of paper-based records. The EHR can track who has access to a record through the audit trail. An audit trail is a chronological set of computerized records that provides evidence of information system activity (log-ins and log-outs, file accesses) used to determine security violations. Audit logs are covered in more detail in chapter 10, Data Security.

Record Processing of EHRs In the EHR, the assembly process is eliminated; however, even if the healthcare organization does not use paper documents, they may receive papers from the patient or other sources. These loose reports are scanned and indexed for inclusion in the EHR. Indexing is the linking of patient name, health record number, document type, and other identifying information to the scanned document.

Record completion in the EHR is performed via computer so healthcare professionals can complete them from any accessible location. An electronic work queue, or workflow, allows the health record to be routed to all healthcare professionals who have deficiencies so that they can access, complete, and authenticate the health record. The work queue is also used to route the health record to HIM for processing. With a document management system, one function does not have to be completed before the next one, so the health record is available for all functions. For example, the health record does not have to be analyzed before it is coded. Also, if coding cannot be performed for some reason, workflow will reroute the health record to coding once the problem has been resolved.

Version Control of EHRs The health record may have multiple versions of the same document; for example, a signed and unsigned copy of a document. Additional versions are also created when addendums, corrections, or amendments are made to original documents. To address the issues that result from having multiple versions of the same document, policies and procedures addressing version control must be developed. Version control identifies which version(s) of the documents is available to the user. All versions must be maintained but access to all except the current version should be controlled so that there is no confusion about which version is correct.

Management of Free Text in EHRs Free-text data are the unstructured narrative data that are the result of a person typing data into an information system. Free-text data are undefined, unlimited, and unstructured, meaning that the typist can type anything into the field or document. The amount of free-text data in the EHR should be limited because the ability to manipulate data is diminished with its use. For example, terms used in structured data are consistent, whereas synonyms may be used in free-text data, making it more difficult to retrieve. The preferred data type is structured text where you point and click or otherwise select the data. For example, you would have two choices with the data element gender: male and female. The user simply points and clicks the appropriate choice rather than typing it in.

In the EHR, the user can copy and paste free text from one patient or patient encounter to another. This practice is dangerous as inaccurate information can easily be copied. Specific risks to documentation integrity of using copy functionality include the following:

· Inaccurate or outdated information

· Redundant information, which makes it difficult to identify the current information

· Inability to identify the author or intent of documentation

· Inability to identify when the documentation was first created

· Propagation of false information

· Internally inconsistent progress notes

· Unnecessarily lengthy progress notes (AHIMA 2014, 4)

Policies and procedures need to be in place to ­reduce some of the risks.

Management and Integration of Digital Dictation, Transcription, and Voice Recognition A common method to capture dictation in the EHR is digital dictation. The physician or other healthcare provider dictates a health report and the transcriptionist types what is said into an electronic, or digital, format. These reports are electronically transmitted into the EHR where the physician can sign the document.

With voice recognition technology, also called continuous speech recognition or continuous speech technology, a computer captures the dictation and converts what is said directly into text and no transcriptionist is needed. The transcriptionist becomes an editor and therefore focuses on data quality. More specifically, natural language processing (NLP) is a technology that converts human language (structured or unstructured) into data that can be translated then manipulated by computer systems. It is the software used for speech recognition.

Reconciliation Processes for EHRs As in the paper-record environment, the HIM professional must verify that there is a complete health record for every episode of care, including both inpatients and outpatients. HIM professionals also need to verify documents sent to the EHR from a transcription system and other information systems arrive in the EHR as expected. For example, all patients admitted to the hospital should have an EHR created for that admission.

Managing Other Electronic Documentation Many documentation sources not previously stored in the paper health record are included in the electronic health record. Examples of these documentation sources include email, voicemail, audio, monitoring strips, images (radiology, pathology), video (heart catheterization), and monitoring (fetal, electrocardiogram).

Email is being used in healthcare to share patient information. Policies and procedures need to be in place to address privacy and security as well as the creation, storage, and maintenance of the messages. The email management system should allow emails containing patient information to be stored in the EHR.

Voicemail containing patient information can also be included in the EHR. The message should include the provider and patient identification, date and time of message, and the date and time of message into the EHR.

Handling Materials from Other Healthcare Organizations When materials are received from other healthcare organizations such as paper health records or diagnostic images, they should be handled per organizational policy; these typically are added to the health records. Some states have laws that address these external health records. If state law does not address health records from other healthcare facilities, then the healthcare organization attorney should be consulted regarding whether to include them in the health record (AHIMA 2011).

Search, Retrieval, and Manipulation Functions of EHRs One of the advantages of the EHR is the ability to search, retrieve, and manipulate health data quickly and easily. This information can be used for patient care, research, and monitoring patient care. In the paper health record, each patient record had to be reviewed individually and data abstracted into a database or another data collection tool. In the EHR, data mining can be performed. Data mining is the process of extracting and analyzing large volumes of data from a database for the purpose of identifying hidden and sometimes subtle relationships or patterns and using those relationships to predict behaviors. Data mining could be used to determine why one physician’s outcomes are better or which medication is the most effective.

Handling Amendments and Corrections in EHRs Policies and procedures need to be in place to address amendments and corrections in the EHR. Once a document is authenticated, the document should be locked to prevent changes. If an amendment, addendum, or deletion needs to be made, the document would then need to be unlocked for editing. Not everyone should have the ability to unlock the documents; the organizational policies should state who has the rights to unlock the ­document (Brown et al. 2012). The EHR should retain the previous version of the document and identify who made the change along with the date and time the change was made. If the change impacts data sent to other information systems, then the change must be made in the other information systems as well.

Quality Control Functions for EHRs Data are collected in several ways: scanning, data entry, bar codes, and transfer of data from other information systems. The information system should have measures in place to control the data entered into the EHR. For example, when entering fields such as the social security number (SSN), an input mask should be used. An input mask shows the format in which the data will be displayed. Entering the SSN, the user should be able to input the number 123456789 and it will appear in the system as 123-45-6789. This prevents one user from entering the SSN as 123456789 and the other as 123-45-6789. A drop-down box that is pre-populated with acceptable entries is another way of controlling what is entered. For example, a drop-down box can be used for states as there are a finite number of states as choices. A checkbox can be used for yes or no type entries. ­Radio buttons allow the user to select from a small number of choices such as male and female in the gender field.

Best practices for designing or evaluating the entry screens are as follows. All these features help ensure the quality of documentation and therefore the quality of patient care.

General guidelines

Clear navigational buttons that direct the user to the next step in the documentation process and buttons to move from one screen to another

Clear labeling of buttons and data fields

Limited 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

Navigation design

Ensure all controls are 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)

Identify required fields

Input design

Simplify data collection

Sequence data input to follow workflow

Provide a title for each screen

Minimize keystrokes by using pop-up menus

Use text-specific boxes to enter text

Use number-specific boxes to enter numbers

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

● Combo boxes

Data validation

Perform a completeness check to ensure all the required data have been entered

Perform a format check to ensure the data are the right type (numeric, alphabetic, and so on)

Perform a range check to ensure the numeric data are in the correct range such as appropriate range for temperature

Perform a consistency check to ensure the combinations of data are correct

Perform a database check to compare data against a database or file to ensure data are correct as entered

Output design

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 (Williams 2006)

Identification Systems

Identification systems link the patient to the health record. The health record number is a key data element in the MPI as it is a unique identifier for the patient. It is used to look up the patient’s health record number. The health record number is typically assigned during the patient’s initial registration encounter at the healthcare organization. The social security number should not be used for the health record due to confidentiality concerns.

There are several ways to identify records in a paper-based health record system. These include numeric, alphabetic, and alphanumeric systems. For numeric systems to work, the health record number must be accessed in the MPI before the health record can be retrieved. The identification systems are serial numbering systems, unit numbering systems, serial-unit numbering systems, and alphabetic filing systems. In the EHR, identifiers such as the health record number, patient name, and more are used.

Paper Health Record – Serial Numbering System

In the serial numbering system, a patient is issued a unique numeric identifier for every encounter at the healthcare organization. If a patient is admitted to the healthcare organization five times, he or she will have five different health record numbers. The documentation for each of the encounters is filed in the health record for that encounter so the information is filed separately, and all health records must be retrieved to view the complete health information. The serial numbering system is inefficient and more costly because of the extra costs to manage the folders as well as to purchase the folders.

Paper Health Record – Unit Numbering System

The unit numbering system is commonly used in large healthcare organizations because it does not have many of the inefficiencies of the serial numbering system. The patient is issued a health record number at the first encounter and that number is used for all subsequent encounters. This system consolidates all the information on the patient in one location and is therefore more efficient than the serial numbering system.

Paper Health Record – Serial-Unit Numbering ­System

The serial-unit numbering system is a combination of the serial and unit numbering systems. The patient is issued a new health record number with each encounter, but all the documentation is moved from the last number to the new number. It would have many of the same advantages and disadvantages as the serial and unit numbering systems.

Paper Health Record – Alphabetic Filing System

The alphabetic filing system is typically used by small clinics and physician offices. The folders are filed alphabetically by the patient’s last name. If there is more than one person with the same last name, then the first and middle initial are used. The disadvantage of this system is that more than one person may have the same or similar name.

Electronic Health Record

The unit numbering system is the most common system used in the EHR. The advantage of the EHR is that identifiers other than the health record ­number—such as the patient name and patient account number—can be used to retrieve the information. The patient account number is a number assigned by a healthcare organization for billing purposes that is unique to a particular episode of care; a new account number is assigned each time the patient receives care or services at the healthcare organization. It is easy to select the wrong person in the EHR, so it is important to double-­check to ensure the correct person is retrieved.

Statistics and Research

Statistics is a branch of mathematics concerned with collecting, organizing, summarizing, and analyzing data. Traditionally statistics utilized by HIM related to patient volume including the number of admissions, number of discharges, and length of stay as manual data collection was time consuming. With the implementation of the EHR, a healthcare organization can easily generate a wide range of statistics. These statistics can be used to manage the business of the healthcare organization as well as to evaluate and improve the quality of the care provided.

Research is an inquiry process aimed at discovering new information about a subject or revising old information. Research utilizes statistics and other methods to evaluate new medical treatments, new drugs, best practices, and so forth. HIM professionals can assist in research through data collection, generating statistics, and data analysis. For more on statistics and research, refer to chapter 13, Research and Data Analysis, and chapter 14, Healthcare Statistics.

Registries

A registry is a collection of care information related to a specific disease, condition, or procedure that makes health record information available for analysis and comparison. Common registries include cancer, trauma, birth defects, and organ transplant. These registries collect data, and generate reports, among other functions. For example, the cancer registry evaluates life expectancy, numbers of cases, and much more. Chapter 7, Secondary Data Sources, discusses registries in more detail.

Birth and Death Certificates

Today, information systems are used to collect and share the data in birth and death certificates. Some, but not all, HIM departments are involved in collecting and reporting that data. The birth certificate data collected include data about the birth, the pregnancy, the parents, and more. Death certificates collect data on the patient, the time of death, the cause of death, and more. Chapter 14, Healthcare Statistics, discusses birth and death certifications, in more detail.

HIM Interdepartmental Relationships

The HIM department cannot manage information in isolation. The HIM department must work with many departments to ensure they have the information that they need to perform their jobs. These departments include the following:

Patient registration. The health record typically begins in patient registration with the capture of patient demographic information. This information is entered into the MPI as discussed earlier. The health record is assigned to new patients during the patient registration process. The HIM department works with patient registration to ensure the quality of the data collected and to correct duplicate and other issues with the MPI.

Billing department (also known as patient financial services). The billing department uses the codes assigned and data abstracted by the coders as part of the billing process. Because of this, the billing department cannot perform their responsibilities until the HIM department completes theirs. The two departments must work together to ensure that all the information required for billing is available.

Patient care departments. The HIM department works closely with nursing units, the emergency department, and other patient care areas to ensure they have access to the patient’s health records from previous encounters. In a paper-based environment, the records are delivered by the HIM staff or picked up by the patient care areas and then the records are returned once they are no longer needed. The departments may send loose reports to the HIM department for filing if the health record has already been returned.

Information systems. The interaction between the HIM department and the information systems department will continue to increase as the EHR becomes more and more important to the organization. The HIM staff works with the information systems staff to plan, implement, and maintain information systems that impact the health record and other systems related to HIM. The information systems department also assists the HIM department with technical issues related to computers, printers, and other hardware. For more information, see chapter 11, Health Information Systems.

Quality management. The quality management department depends on the health record to complete their functions. They need health records for committee meetings, audits, and outcome monitoring. HIM staff may collect some of the data needed, provide the records, generate statistics, write reports, mine data, or assist in other ways.

Virtual HIM

Much of the work of the HIM department can be performed remotely due to the implementation of the EHR. Some healthcare corporations have centralized their HIM services into a single location. Many healthcare facilities have employees who work at home. Common functions that can be performed from home ­include coding and transcription, but others can be performed remotely as well. The manager must ensure the employees are able to work independently so that productivity standards can still be met. Chapter 1, Health Information Management Profession, discusses the future of the HIM profession in more detail.

HIM Information Systems

The HIM department cannot perform the functions of the department efficiently without the use of information systems. These information systems assist in health record processing, provide access to patient information, and more. Some of these information systems are becoming more and more important with the implementation of the EHR while others will be phased out completely as the EHR makes them obsolete. The information systems include disclosure of health information, chart tracking, coding, registries, billing, quality improvement, and electronic health record.

Disclosure of Health Information

The systems that track the disclosure of health information track requests for information from patients, insurance companies, and other requesters. HIM staff enters basic information from the request such as the patient name, health record number, and who is requesting the health record. Once the patient information is released, the staff records what information is released and the date. The information system can bill requesters for the copies of records, when appropriate. It can monitor productivity, turnaround time, and more.

Chart Tracking

This information system currently tracks the location of the health record but will eventually become obsolete when paper health records are eliminated. The chart tracking information system records who checked it out, where it went, and how long it has been checked out. It also records when the health record returns to the HIM department.

Coding

Coders use two specialty information systems—encoders and groupers. An encoder assigns the diagnosis and procedure codes. The encoder assists in the coding process as it reminds coders to check for important diagnoses and procedures and provides easy access to coding resources. The grouper uses the codes assigned to determine the diagnostic-­related group or another grouping. (See chapter 15, Revenue Management and Reimbursement, for specifics on diagnostic-related groups.) Some healthcare organizations are now using computer-assisted coding (CAC), which uses EHR data to assign the codes. With computer-assisted coding, the HIM professional monitors the quality of the codes assigned by the information system rather than assigning the code.

Registries

As stated earlier in this chapter, registry is a database on specific diseases and procedures; for example, cancer and transplant registries are common ones. In the registry, data regarding the diagnosis, procedure, or other concept is captured and can be used for research, patient care, and quality monitoring. The data captured and functionality varies by the type of registry. Chapter 7, Secondary Data Sources, discusses registries in more detail.

Billing

The HIM department may or may not directly use the billing system. The encoder and grouper may submit the codes and other data directly to the billing system or it may be entered manually by the coder. The HIM department does not create the bill but rather provides information that is included on the bill.

Quality Improvement

Quality improvement systems go by many different names and perform a number of functions. Characteristically, they are repositories of data that are used to monitor trends, generate statistics, monitor outcomes, and improve the quality of the documentation in the EHR. The data may be collected from the EHR or be manually entered by HIM professionals.

Electronic Health Records

The EHR utilizes several information systems to capture patient information. These source systems supply the EHR with demographic information, test results, dictated reports, and more. The EHR also has clinical decision support (CDS), which assists physicians and other users when making decisions regarding medications, diagnoses, and such based on the information entered into the EHR. The EHR contains alerts and reminders to notify the user of medication allergies, tests that should be performed, immunizations due, and so forth. Benefits of the EHR include reduction in administrative costs and improvement in quality of care. The healthcare organization becomes more efficient with the improved accessibility to health information.

Personal Health Records

A personal health record (PHR) is an electronic or paper health record maintained and updated by an individual for himself or herself; a tool that individuals can use to collect, track, and share past and current information about their health or the health of someone in their care. The PHR provides a way for a patient to be involved in his or her healthcare. It is not the same as an EHR, but rather is a subset of the information that is available to and controlled by the patient. The patient can add information to the PHR, such as over-the-counter medications and self-administered blood glucose test results. The PHR is especially useful for patients with complex, chronic conditions. The healthcare provider or the insurance company may provide the PHR, or the patient may purchase or subscribe to it from a commercial vendor. Refer to chapter 12, Healthcare Information, for additional details.

Figure 3.1 Input screen for an electronic MPI system

Source: MEDITECH Registration. Used with permission from MEDITECH Practice.

Figure 3.2 Rules for alphabetic filing

Source: Huffman 1994.

Figure 3.3 Terminal-digit filing system example

Source: ©AHIMA.