Unit IV HTH

HTH 2305, Health Information Documentation Management 1

Course Learning Outcomes for Unit III At the end of this unit, you should be able to:

1. Utilize health information systems to manage patient medical records. 1.1 Locate patient health data in an electronic health record system.

4. Apply compliance standards that govern how patient information is collected, stored, and transmitted.

4.3 Define HIPAA best practices for managing patient medical data.

Required Unit Resources Chapter 11: Filing Procedures (ULOs 1.1 and 4.1) Read pages 312-325. Chapter 12: Medical Records (ULOs 1.1 and 4.1) Read pages 326-337.

Unit Lesson Lesson: Mastering Medical Record Management (Part 1) (ULOs 1.1 and 4.1)

Filing Management All healthcare professionals are responsible for properly managing medical files that contain protected health information (PHI) as well as ensuring that Health Insurance Portability and Accountability Act (HIPAA) regulations are met. When healthcare practices and facilities select a filing system, there are several things that should be considered. This includes the total number of active patient records and inactive records, frequency of medical records retrieval, the amount of filing space provided, cost of the system, and size of the medical practice or healthcare facility. Paper-Based Filing Systems vs. Electronic-Based Filing Systems Paper-based filing systems most commonly use alphabetic name sequencing because this is easy to understand and does not require a cross-referencing index. Color coding is often used with alphabetic filing systems, with colored tabs corresponding to each letter of the alphabet. This helps healthcare staff quickly and accurately find a patient’s medical record based on the colors of the letters. For example, Mary Smith would have the following letters on the outside of her chart: SMM. The letter S may be green, and the letter M may be blue. This makes it easy for the patient’s record to stand out if it is accidentally misfiled and is important for quick retrieval. Indirect filing systems are good for adding an additional layer of security and privacy to sensitive patient information. These types of systems are also referred to as numerical filing systems, which have often been used in hospitals, clinics, and larger medical practices. While these systems may be a bit more complex than the alphabetic filing system, they offer an advantage with added protection against unauthorized users. Making sure that staff members understand indirect filing systems is key, so training and education sessions should be provided periodically.

UNIT III STUDY GUIDE

Mastering Medical Record Management (Part 1)

HTH 2305, Health Information Documentation Management 2

UNIT x STUDY GUIDE

Title

Electronic filing systems, such as electronic medical records (EMRs) or electronic health records (EHRs), are legal documents with information that is managed by healthcare professionals. These systems use an electronic security system to help always protect and maintain patient confidentiality. Electronic records need to be secured, permitting access only by authorized individuals. HIPAA provides a Security Rule, which maintains physical safeguards, such as how to access and control a workstation. These are also technical safeguards, which are used as auditing processes, integrity controls, and transmission security procedures. Facilities will use encryption, a process used for security measures to maintain confidentiality. If accessed by unauthorized users, the information becomes unreadable. Additionally, security codes, such as usernames and passwords, are distributed to employees for access. If an employee is terminated for any reason, their access will end. Another safeguard that is put in place by the information technology (IT) department is recording the dates and times when users are signed into the electronic filing system and when they are accessing patient data. Logs or reports can be reviewed by management as an audit process to help ensure compliance. All healthcare employees should follow electronic confidentiality guidelines to avoid any potential breaches of PHI. These measures include never leaving storage media unattended, always logging off computers before leaving a workstation, never writing down a username and password for others to find, and changing passwords regularly. Other guidelines include never downloading public domain files or software (as these may contain a virus) and backing up files regularly. Following these guidelines will increase the safety and confidentiality of patient information. Electronic Health Record System Adoption Case Studies The adoption of electronic health record (EHR) systems has greatly transformed healthcare delivery, efficiency, patient safety, and care coordination. The goal of an EHR system is to promote a seamless transfer of information with the goal to improve the patient’s medical outcome. Recent studies provide valuable insights into this trend and highlight some of the benefits and challenges that are associated with EHR implementation. In 2021, the Office of the National Coordinator for Health Information Technology (ONC) revealed the results of a study outlining the substantial increase in national EHR adoption. As of 2021, 78% of office-based physicians and 96% of hospitals currently use an electronic health record (EHR) system (ONC, 2024). Over the past ten years, this adoption rate has more than doubled as more and more healthcare providers are transitioning to computerized medical record systems. Not only has the adoption of EHRs increased in the United States, but healthcare scientists have also begun to study its effects throughout the world. EHR systems have transformed healthcare in developed countries, and now implementation is starting in low- and middle-income countries. A study conducted in 2023 in the country of Ghana set out to explore the perception of EHR systems and to gauge Ghanaian healthcare professionals' satisfaction level. The results of this study concluded that 81% of the healthcare professionals surveyed perceived EHRs as beneficial to patients and were satisfied with using the systems. Most healthcare professionals said that the EHR systems improved workflow processes (Mensah, 2024). While the findings were in favor of electronic health record systems, these professionals did voice concerns. One concern involved the privacy and confidentiality of patient information. Patient information should not uphold patient medical rights. Another concern raised by the Ghanaian healthcare professionals were issues with unstable power supply and poor internet connectivity. While this is something that is more prevalent in low- and middle-income countries, it does bring the topic of sustainable resources to the conversation. Lack of resources can be one barrier to EHR implementation. EHR systems have provided great advances in healthcare information technology. However, there are some disadvantages or challenges that can come with implementing an EHR system, including financial cost. Healthcare decision-makers know that the implementation of an EHR system can be expensive for some providers. To promote and assist in the adoption of EHR systems, federal governments provide incentives to

HTH 2305, Health Information Documentation Management 3

UNIT x STUDY GUIDE

Title

organizations. Provisions in legislation like the HITECH Act aim to reduce some of the financial burden that adopting an EHR system can have on a healthcare system. Once an EHR system is implemented it is important to monitor how employees interact with the system and gauge their feedback. A study published in 2020 sought to study the negative effects of EHR systems. The findings of that study outlined positive, as well as negative effects, of EHR implementation through conducting surveys with health information professionals who use EHRs. Some challenges that were mentioned in the study were poor training and technical support, increased workloads, and a decrease in efficiency (Tsai, 2020). While the overall study was positive for electronic health record use, the challenges are worth discussing and can be used to create a user-friendly EHR system. One way to address this issue is to make sure that there is effective training on how to navigate the specific EHR system. The study also shed light on one consequence of learning a new system: increased workloads for employees. According to this study, some employees feel that while EHRs save time in some aspects, they have also caused an increase in workload which can decrease morale in the long run. EHR systems have transformed the landscape and health information management, but with that efficiency comes some concerns, challenges, and barriers that we must continue to monitor. Record Retention, Storage, and Destruction There are federal and state laws that relate to the requirements of maintaining records. Records must be maintained based on the statute of limitations, and if both federal and state laws do not all agree with the time frame, the best practice would be to keep the record for the longest period noted. On average, most states will require medical records to be kept anywhere between 7 to 25 years. A records retention schedule helps to ensure that these documents are kept according to the applicable state or federal law but are not kept without cause. A retention schedule will be used to show a particular list of records and the length of time that each record should be retained. There are some important steps to this process for successful records retention. Consistently move active patient records to inactive records. Make sure to clearly label the type of record and the “from” and “to” dates of the material to quickly retrieve information in the future. Common ways that healthcare facilities will destroy records are either by contracting with an outside vendor who will pick up and dispose of these documents or by placing shredders within the facility for quick destruction. Electronic record archiving is a great way to save space while ensuring that older, inactive information can still be accessed. There are a few locations that can house these archived records to include offsite network systems, cloud storage, and/or external hard drives. In many cases, it may not be best to destroy computerized medical records, but in the event it becomes necessary, follow the organizational procedure to remove all sensitive data. Medical Records A patient’s medical record is a legal document. It is a record of information, factual data, events, and care administered to the patient. Medical records contain personal, confidential data that includes both medical history and care. Medical records are used in all aspects of the healthcare delivery system, requiring consistent maintenance. These records assist in the diagnosis and treatment of a patient, evaluating, and providing appropriate care, and verifying that services rendered were medically necessary. Medical Record Organization Systems There are three basic types of medical record systems used by most healthcare facilities. These include the problem-oriented medical record system, the source-oriented record system, and the integrated record system. The problem-oriented medical record (POMR) system includes data and lists, which provide a description of all a patient’s permanent and temporary health problems. The patient’s medications are also cross-referenced by number to the health problem for which they were prescribed. Progress notes, flow sheets, charts, and graphs are all available for the provider to review at a glance. It is an organized method that allows for faster diagnosis and treatment of a patient.

HTH 2305, Health Information Documentation Management 4

UNIT x STUDY GUIDE

Title

The source-oriented record (SOR) system is a common paper-based management system. Documents in the medical record are arranged by sections (e.g., by progress notes, radiology, laboratory, and medication lists). The overall sequencing of these sections varies by preference. A drawback to this method is that it can be challenging to see an overall picture of the patient’s problem since documentation tends to be filed in different sections of the medical record. The integrated record system is the third common medical record organization method, which files all medical documents in chronological order regardless of the source or type of record. This can pose a challenge at times if the physician is attempting to compare previous laboratory or radiology testing as the results may be in several different locations within the medical record. It is important to handle any adjustments to medical records promptly and appropriately to prevent any legal issues. Healthcare professionals should never erase entries or use correction fluid on handwritten or typed entries, which could prevent others from reading the original entry. If the physician discovers an error, corrected information must be added as an addendum. Within an EHR, this process is a little easier in that the system allows for making amendments, tracking corrections, and identifying the original entry in a seamless manner.

Conclusion In this unit, we have reviewed important information related to accurate filing procedures and practices that involve both electronic and paper-based filing systems. These included examples of benefits and challenges. Additionally, we discussed medical record retention and appropriate destruction techniques. We also focused on the importance of safeguarding a patient’s medical record. There are three types of medical record organization systems used; these include the POMR, SOR, and the integrated record, each having its own advantages and disadvantages. All supporting documentation should be readily available and precisely accurate to avoid possible issues or ramifications.

References French, L. L., & Turner, L. H. (2024). Administrative medical assisting (9th ed.). Cengage. Mensah, N. K., Adzakpah, G., Kissi, J., Abdulai, K., Taylor-Abdulai, H., Johnson, S. B., Opoku, C., Hallo, C.,

& Boadu, R. O. (2024, September 16). Health professionals’ perceptions of electronic health records system: A mixed method study in Ghana - BMC Medical Informatics and decision making. BioMed Central. https://bmcmedinformdecismak.biomedcentral.com/articles/10.1186/s12911-024-02672-3

National trends in hospital and physician adoption of Electronic Health Records. HealthIT.gov. (n.d.). https://www.healthit.gov/data/quickstats/national-trends-hospital-and-physician-adoption-electronic- health-records

Tsai, C. H., Eghdam, A., Davoody, N., Wright, G., Flowerday, S., & Koch, S. (2020, December 4). Effects of electronic health record implementation and barriers to adoption and use: A scoping review and qualitative analysis of the content. Life (Basel, Switzerland). https://pmc.ncbi.nlm.nih.gov/articles/PMC7761950/

Suggested Unit Resources (Optional) Article: National Trends in Hospital and Physician Adoption of Electronic Health Records This article provides statistics on electronic health record (EHR) adoption in US hospitals and physicians’ offices (2 pages). (Optional) Article: Effects of Electronic Health Record Implementation and Barriers to Adoption and Use: A Scoping Review and Qualitative Analysis of the Content This article reviews 7000+ studies on the effects of EHR adoption and the barriers and challenges that come with implementing electronic health information systems (26 pages).