Powerpoint for Health Information Technology

HEALTH INFORMATION PRACTICUM I – HIT-130-1406

Professional Practice Experience

Sinai Hospital

Under the supervision of: Michele D’ Ambrosio, Assistant Vice President Health Information Management Department Miasia Smith, Manger, Operations Kara Rogan, Manager, HIM Systems & Data Intergrity Ericka Kelly, Manager, LBH Coding Baltimore City Community College Instructor: Professor Singleton Student’s name: N/A

Table of Contents:

1. INTRODUCTION OF THE ORGANIZATION 3

2. CHART RETRIEVAL 3-4

3. PREPPING 4-5

4. SCANNING 5

5. REVIEW 6-7

6. ANALYSIS 7-8

7. CHART REVIEW 8-9

8. RELEASE OF HEALTH INFORMATION 9-11

9. SYSTEMS 11-13

10. EMPI 13-14

11. POLICIES and PROCEDURES 14-17

12. PERSONAL EXPERIENCE 17-20

13. CONCLUSION 20

14. APPENDIX 21-28

i. ORGANIZATION CHART 21

ii. DATAVANT 22

iii. AUTHORIZATION FOR MEDICAL RELEASE 23-24

iv. PRACTICUM SCHEDULE 24-25

v. STUDENT EVALUATION 25-26

vi. CLINICAL SITE EVALUATION 27-28

1. Introduction of Organization

The Health Information Management (HIM) Department at Sinai Hospital plays a vital role in ensuring the seamless management and safeguarding of patient health records. As a critical hub within the hospital, the HIM team oversees the collection, organization, and maintenance of accurate medical information to support quality care, regulatory compliance, and operational efficiency.

This dedicated department is responsible for maintaining electronic health records (EHRs), coding diagnoses and procedures, and ensuring secure access to patient information while upholding privacy and confidentiality in accordance with HIPAA and other healthcare regulations. The HIM professionals at Sinai Hospital work closely with clinical teams, administrative staff, and patients, bridging the gap between healthcare delivery and essential data management.

With a focus on innovation and integrity, the Sinai Hospital HIM Department is committed to leveraging advanced technologies and best practices to enhance patient outcomes and streamline hospital operations.

2. Chart Retrieval

Chart retrieval at LifeBridge Health is an essential part of the document management process, ensuring that patient records are accurately collected, processed, and stored. Medical documents, including charts and emergency room (ER) charts, are picked up by LifeBridge personnel from various facilities and delivered to a central location twice daily, typically around 9 a.m. and 12 p.m. Once the documents arrive, they are sorted among the team into groups called "batches." This organization facilitates efficient processing. After sorting, staff begin the preparation phase, where they review and organize the batches for scanning and integration into the Electronic Health Record (EHR) system. This meticulous process helps maintain the integrity and accessibility of patient records, supporting the continuity of care across LifeBridge Health facilities.

3. Prepping

In the Health Information Management (HIM) department at LifeBridge Health, prepping is a critical step in creating and organizing patient health records. The process begins by measuring each batch of documents with a ruler to ensure accuracy and consistency in handling. Next, the census is reviewed to verify that all patients listed are accounted for in the batch received, with no missing records. Each batch is then meticulously examined to separate unnecessary materials, such as duplicate or irrelevant documents, from essential medical records. This careful sorting ensures that only the necessary information is retained for the patient’s health record. Once organized, the documents are arranged in order by discharge date to facilitate easy access and processing. After the prep work is completed, the batches are scanned into the system, where they are ready for the reviewer to finalize and integrate into the Electronic Health Record (EHR). This process ensures accuracy, efficiency, and compliance in maintaining patient health records.

4. Scanning

In the HIM department at LifeBridge Health, the scanning process is a key step in digitizing patient records for secure electronic access. Once batches are prepped, they are transported to the scanning room, where they are organized by categories, such as Northwest inpatient charts, Northwest ER records, and other facility-specific groupings under LifeBridge Health. Each batch is carefully reviewed before and after scanning to ensure quality control. This involves checking for duplicate records, confirming that all scanned documents are clear and legible, and removing any blank pages.

After the scanning process is complete, a cover sheet is added to the batch, and the physical documents are transferred to the filing room. There, they are securely stored for 30 to 60 days before being collected by the shredding company. This ensures compliance with confidentiality and privacy standards. Once the physical documents are shredded, the process is finalized, and the records are permanently available for electronic viewing, enabling seamless access for clinical and administrative use. This thorough system underscores LifeBridge Health’s commitment to efficient and secure health information management.

5. Review

In the HIM department at LifeBridge Health, the document review process is essential for ensuring the accuracy and completeness of patient health records. During this process, the Lead Tech II audits the scanned charts for any deficiencies, verifying that the correct patient record number is linked to the right documents. Solarity Software is used by the reviewer to assist in the document review, enabling a thorough examination of each batch. Once a batch of records is scanned, every page within it is carefully checked for proper indexing, image clarity, and correct patient identification, including the patient's name, medical record number, and account number. Records are further validated by the Clinical Documentation Improvement (CDI) team and reviewers to ensure accuracy.

Any documents that are not properly annotated are discarded. The review also focuses on identifying and correcting errors, such as incorrect medical record numbers, misfiled documents, missing HIPAA forms, wrongly indexed visits, or improperly split documents. The goal of this auditing process is to identify and correct errors before the records are finalized, ensuring that they are accurate and complete.

If fatal errors are found, the Lead Tech II takes action by emailing staff at other LifeBridge Health facilities to inform them of the issues. These errors are then corrected, and the updated records are pushed through the system, ensuring that all records are properly processed. This rigorous review process helps maintain high standards of accuracy and integrity in patient health records.

6. Analysis

The role of the Documentation Specialist ensures that patient records are complete and accurate. One of the key responsibilities in this role is reviewing refusals and auditing records for missing items. Missing items typically include unsigned or absent notes, such as History and Physical (H&P) reports, Progress Notes, or Discharge Summaries. The Documentation Specialist checks for these deficiencies and assigns them to the responsible physicians when necessary, ensuring that the patient’s record is comprehensive.

If a document is missing or unsigned, the HIM department uses PowerChart to send messages to the physicians, requesting completion of the required notes. Physicians can provide a rebuttal if they disagree with the deficiency being assigned to them. If the missing items are not addressed within a specific timeframe, the records are placed on suspension until the deficiencies are corrected. This process ensures that all required documentation is completed in a timely manner.

Once the missing items are added and signed by the physician, the HIM department reviews them to confirm the record's completeness before scanning them into the Cerner system. This ensures that all patient information is accurately captured and available for electronic access, supporting high-quality care and compliance with healthcare standards.

7. Chart Review

The chart review role in the HIM department at LifeBridge Health is critical for maintaining the integrity and reliability of patient records. This role involves meticulously reviewing medical charts through PowerChart to ensure that essential documents are present and accurately recorded in the Electronic Health Record (EHR) for various types of cases, including Inpatient, Outpatient, and Behavioral Health. This process supports the seamless flow of accurate information across the continuum of care and ensures compliance with healthcare regulations.

A key responsibility in chart review is verifying that data has been processed correctly and in the appropriate sequence. This requires a multidisciplinary approach where physicians and other medical staff contribute to the completeness of the records. The review process evaluates specific indicators that address the timeliness, readability, and overall completeness of information within the medical record. This ensures that all documentation meets professional and regulatory standards, facilitating effective communication and decision-making among healthcare providers.

Charts are examined to confirm the presence of critical documents, such as History & Physicals, Operative Reports, Post-Anesthesia Notes, Post-Operative Notes, and Discharge Summaries. Particular attention is paid to discharge summaries, as they play a vital role in patient care continuity. A discharge summary that is not signed by the physician is marked as a preliminary report, and it only becomes a final report once it is signed. This distinction is crucial for ensuring that the record is finalized and usable for clinical, legal, and billing purposes.

By performing these detailed reviews, the chart review role helps identify and address deficiencies, ensuring that the EHR is accurate, complete, and up to date. This process safeguards the quality of patient care, supports efficient workflows, and enhances compliance with accreditation and auditing requirements. It is a vital component of LifeBridge Health’s commitment to delivering exceptional healthcare services.

8. Release of Health Information

The  Release of Health Information role in the HIM department at LifeBridge Health is essential for managing the secure and accurate distribution of patient medical records. While LifeBridge Health has partnered with Datavant Health, an outsourced company, to handle medical records, the operations are still located within the Medical Records department at Northwest Hospital. Requests for medical records are received through various channels, including walk-ins, electronic submissions, and paper forms. Each request must include an Authorization of Release of Medical Records form, which can originate from a variety of sources such as patients, attorneys, insurance companies, or the court system. These requests cover a broad range of record types, including medical records, outpatient visits, emergency room visits, and procedural documentation. On average, 50–60 requests are processed daily.

The systems used to facilitate this process include Datavant, Cerna, RightFax, Revenue Cycle, Wellington, and Athena IDX. These platforms help ensure that records are accurately identified, compiled, and distributed in accordance with strict timelines. Although state regulations allow up to 21 days to fulfill requests, LifeBridge Health sets a higher internal standard of a 5-day turnaround time. This commitment to efficiency underscores the organization’s dedication to patient service and compliance.

Accuracy is paramount in this role, as even minor mistakes can have serious consequences, such as a HIPAA violation or legal repercussions. Therefore, all requests and associated documents are meticulously reviewed before being sent out. To maintain high standards, LifeBridge Health implements a performance monitoring system with a point-based disciplinary policy. Accumulating 12 points can result in termination, emphasizing the importance of attention to detail and adherence to protocols.

By ensuring that all medical records are handled securely and efficiently, the Release of Health Information role not only supports the facility’s compliance with state and federal regulations but also builds trust with patients and external entities. This rigorous process ensures that LifeBridge Health remains a reliable and compliant healthcare provider while safeguarding sensitive patient information.

9. Systems

The  Systems role in the HIM department at LifeBridge Health plays a vital behind-the-scenes function in ensuring the smooth operation of various IT systems that support health information management processes. This role is responsible for resolving IT issues and ensuring that all technology platforms are functioning optimally. A variety of systems are used across the department, including Access HIM, Citrix, Kofax, 3M, Escription, Iodine Interact, Review Mate, and other IT ticketing systems. These systems support different aspects of medical record management, such as scanning, document indexing, coding, and electronic document review. The role ensures that any technical issues affecting these systems are promptly addressed, allowing HIM staff to continue their work without disruption.

One of the key tasks of the Systems role is troubleshooting when documents fail to transfer correctly between systems. For example, if documents do not push over from Solarity to the appropriate platform, the Systems team investigates the issue to determine why it occurred and corrects any errors in the data transfer process. Such discrepancies can happen for various reasons, including system malfunctions or errors in the indexing of documents. In such cases, the Systems team works with HIM staff to pinpoint and resolve the underlying issue, ensuring that the documents are properly integrated into the Electronic Health Record (EHR).

Another area of responsibility is ensuring the accuracy of coding and compliance with coding standards. The Systems role monitors background applications for issues such as coding errors or duplicate forms, which can lead to coding discrepancies. Code checks are an essential part of the system, and when the coding is incorrect, it can cause "kickbacks" or rejections. The Systems team investigates why certain records or codes were flagged by the system, identifies the root cause of the issue, and makes necessary corrections. These kickbacks, often related to misfiled information or incorrect codes, can delay processing, so quick resolution is crucial.

Requests for IT support or issues are typically handled through a formal process, where the Systems team receives notifications via email or through the help desk system. The team then prioritizes these requests and works on troubleshooting and resolving technical issues that may hinder the smooth processing of medical records, ensuring that LifeBridge Health remains compliant and efficient in managing health information.

The Systems role is essential in maintaining the integrity of the HIM department’s work. By managing and resolving IT issues swiftly and efficiently, the team helps ensure that healthcare providers have the right tools and technology to maintain accurate, up-to-date, and accessible patient records. This role not only supports operational efficiency but also plays a critical part in safeguarding sensitive patient data and ensuring the organization’s compliance with regulatory standards.

10. EMPI

The HIM Systems and Data Integrity role at LifeBridge Health is essential for maintaining the accuracy and reliability of patient health information within the organization's electronic health systems. This role focuses on reviewing medical records to ensure the appropriate coding of diagnoses and procedures, using ICD-10-CM and CPT codes with applicable modifiers. Adherence to standard coding guidelines and LifeBridge Health (LBH) protocols is critical to ensure accurate data for clinical quality, reimbursement, and reporting purposes.

One of the key responsibilities is the review and correction of various data fields that impact the accuracy of information used for Health Services Cost Review Commission (HSCRC) reporting, quality measures, and reimbursement processes. The department uses a range of reports and system-generated queues to identify and resolve data discrepancies. These efforts ensure that the organization meets regulatory standards and maintains data integrity for all healthcare operations.

A significant aspect of this role involves resolving issues that arise in patient records. For example, errors such as merged patient records, where two individuals are mistakenly assigned the same Medical Record Number (MRN), must be corrected. These patients must be “unmerged,” and their records separated to ensure that their health data is accurate and attributable to the correct individual. Similarly, duplicate MRNs must be identified and resolved to prevent data redundancy or errors in patient care.

Another challenge involves ensuring that data from various sources, such as lab results, is correctly matched to the appropriate patient record. In some cases, mismatched or missing data can occur, necessitating prompt investigation and correction. The HIM Systems and Data Integrity team plays a pivotal role in identifying such issues and taking corrective actions to maintain the accuracy and reliability of the health record system.

In addition to correcting errors, this role also involves educating team members and other stakeholders about how these issues arise and the processes for addressing them. This helps build awareness across departments and contributes to the prevention of similar problems in the future. By maintaining high standards of data accuracy, the HIM Systems and Data Integrity department ensures that LifeBridge Health can deliver safe, high-quality care and meet its compliance obligations effectively.

11. Policies and Procedures

The Policies and Procedures in the HIM department at LifeBridge Health establish a framework for managing health information in a manner that ensures accuracy, compliance, and confidentiality. These guidelines are critical for maintaining the integrity of patient records and ensuring that LifeBridge Health adheres to regulatory standards, such as HIPAA, state laws, and accreditation requirements. They cover various aspects of health information management, including data entry, record maintenance, release of information, and documentation processes.

Confidentiality and Security

One of the most fundamental policies in the HIM department is safeguarding patient information. Staff are trained to handle health records in compliance with HIPAA (Health Insurance Portability and Accountability Act) regulations, ensuring that patient confidentiality is always protected. Access to patient records is restricted to authorized personnel, and all activities involving the use or disclosure of health information are logged and monitored. This ensures that the organization remains accountable and that any potential breaches of patient confidentiality are addressed promptly.

Record Maintenance and Accuracy

The HIM department also follows detailed procedures for the creation, storage, and maintenance of medical records. Policies dictate how records should be organized, including the proper indexing of documents and assignment of accurate ICD-10-CM and CPT codes. Regular audits are conducted to verify the completeness and accuracy of patient information. Staff are required to follow standardized protocols for correcting errors, such as duplicate records or misfiled documents, ensuring that the information remains reliable for clinical, legal, and billing purposes.

Release of Information

The release of medical records is governed by strict policies to prevent unauthorized access or disclosures. Requests for information, whether from patients, attorneys, insurance companies, or other entities, must be accompanied by an Authorization of Release of Medical Records form. LifeBridge Health enforces stringent timelines for processing these requests, with an internal standard of five days compared to the 21-day state requirement. This proactive approach ensures timely service while maintaining compliance with legal and regulatory requirements.

Documentation Standards

Policies within the HIM department emphasize the importance of timely, readable, and complete documentation in patient records. Physicians and medical staff are required to adhere to these standards, and the HIM department actively monitors compliance. Procedures are in place to address deficiencies, such as unsigned discharge summaries or missing notes, and to assign corrective actions as needed. These measures ensure that patient records meet both clinical and regulatory standards.

Staff Accountability and Performance

LifeBridge Health implements a point-based performance monitoring system to ensure accountability within the HIM department. Errors such as HIPAA violations, missed deadlines, or repeated mistakes are tracked, and employees can face disciplinary action if performance expectations are not met. This system fosters a culture of responsibility and continuous improvement among staff.

Continuous Improvement and Training

Policies and procedures are not static; they are reviewed and updated regularly to reflect changes in regulations, technology, and industry best practices. Staff receive ongoing training to stay informed about updates and to ensure that they can effectively implement the latest protocols.

By adhering to these comprehensive policies and procedures, the HIM department at LifeBridge Health ensures the secure, efficient, and compliant management of health information. This not only supports the delivery of high-quality patient care but also reinforces the organization's reputation for excellence and accountability in healthcare.

12. Personal Experience

I thoroughly enjoyed my clinical practicum at the Sinai Hospital HIM department under LifeBridge Health. From the moment I arrived, the experience was structured and organized. Operations Manager Miasia Smith had my schedule pre-planned, making it easy to follow and understand what tasks I needed to perform each day and at specific times. This level of organization made the practicum both educational and enjoyable.

Days 1–3: Prepping and Scanning Charts

During my first three days, I worked alongside HIM Tech Shirley King, who provided hands-on training on prepping and scanning charts. This process involved preparing patient charts for transfer into the system, ensuring they were ready to become part of the Electronic Health Record (EHR). I quickly grasped the process and even contributed by helping the team process charts. The experience was valuable as it showcased how patient records are digitized, ensuring they are available electronically for clinical use.

Days 4–5: Chart Auditing

On the fourth and fifth days, I observed and trained with Lead HIM Tech II Karine Stine who audited the charts after they had been scanned into the system. This role involved meticulously reviewing scanned records for proper indexing, image clarity, and correct patient identification, such as ensuring the accuracy of the patient’s name, medical record number, and account number. This step is crucial to maintaining the integrity of patient records. Additionally, I learned about the role of the Clinical Documentation Improvement (CDI) team, which further validates records to ensure completeness and accuracy. This experience demonstrated the importance of maintaining high standards in record auditing.

Days 6–7: Analysis Team

Next, I worked with the Analysis Team Lonnie, Nicki, and Jocelyn who taught me about ensuring the completeness and accuracy of patient records. I participated in reviewing medical charts through PowerChart, verifying that essential documents like History & Physicals, Progress Notes, and Discharge Summaries were present and properly recorded for various cases, including inpatient, outpatient, and behavioral health. This role also involved assigning deficiencies to attending physicians and residents for incomplete charts. For instance, unsigned notes or missing documentation are flagged, and follow-up is coordinated to ensure compliance. I appreciated having hands-on experience with this process and understanding its impact on patient care and regulatory compliance.

Days 8–10: Medical Records Department

For the next three days, I worked in the Medical Records Department at Northwest Hospital under Patricia Pegues. Here, I gained insight into how medical record requests are managed. Requests come through various channels, including walk-ins, electronic submissions, and paper forms, and they can originate from patients, attorneys, insurance companies, or court systems. I actively participated in the process, understanding how to process and deliver these requests accurately and on time.

Day 11: HIM Systems and Data Integrity

On the eleventh day, I trained with Ryan and Kara, who introduced me to two critical roles. Kara explained the HIM Systems and Data Integrity function, which involves reviewing medical records for coding accuracy, adhering to ICD-10-CM and CPT coding standards, and ensuring compliance with LifeBridge Health protocols. This role focuses on ensuring data quality for clinical use, reimbursement, and reporting purposes. Ryan provided an overview of the Systems Role in the HIM department, highlighting the behind-the-scenes work to resolve IT issues, maintain smooth system operations, and investigate system errors such as document processing issues in Solarity. Both roles were insightful, showing how technology supports health information management.

Day 12: Coding Department

On the final day, I shadowed Ericka in the coding department. She walked me through the coding systems and processes used to assign accurate codes to patient records for insurance claims. I observed how coders access tasks through the HIM Task Queue, analyze patient records, and assign severity-of-illness codes. While I couldn’t code charts myself, I gained an understanding of how queries from multiple stakeholders are resolved and how coders play a vital role in ensuring the integrity of medical billing and reimbursement.

13. Conclusion

My time at Sinai Hospital HIM department was a comprehensive learning experience. Each team member I worked with contributed to my understanding of the essential functions within Health Information Management. From prepping and scanning charts to analyzing records, managing medical requests, and understanding coding systems, I gained valuable hands-on experience and knowledge. This practicum highlighted the importance of accuracy, compliance, and teamwork in ensuring that health information supports both patient care and organizational efficiency.

APPENDIX i

Organization Chart

APPENDIX ii

Datavant

APPENDIX iii

Authorization for Medical Release

APPENDIX iv.

Practicum Schedule

APPENDIX v.

Student Evaluation

APPENDIX vi.

Clinical Site Evaluation

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