Ahima2010 Summer Presentation Writ Kohn


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Ahima2010 Summer Presentation Writ Kohn

  2. 2. Learning Objectives1. Understand the importance of managing Electronic Health Records (EHRs) as business records.2. Manage the process of electronic records management for evidentiary discovery purposes.3. Review information systems capable of creating electronic health records, such as eMail systems, dynamic Web site systems, and PACS.4. Create a comprehensive plan for the life cycle management of the organization’s electronic business records. © 2007
  3. 3. Today’s Healthcare OrganizationMounds of analog paper and film records still exist. © 2007
  4. 4. Today’s Healthcare Organization  However, more digital / electronic records are created than analog records.  EVERY MINUTE:  servers log thousands of network interactions  staff members create hundreds of eMail messages  databases record gigabytes of information © 2007
  5. 5. Trade Off? Digital / electronic records / film might take up less physical space than their predecessors, but they remain business records that might be subpoenaed for medical malpractice lawsuits or other legal actions. © 2007
  6. 6. Managing Electronic Records/Film  As such, the management of electronic records / film requires the same rigorous principles applied to analog paper records / film. © 2007
  7. 7. Way Back When… 1970s Acknowledging Subpoenas COURTS REQUIRED  The physical delivery of ―original,‖ analog source documents / records.  Only rudimentary paper photocopy machines existed (thermo facsimiles) © 2007
  8. 8. Way Back When… 1970s Deborah’s cardboard box approach! © 2007
  9. 9. Way Back When… 1980s - 1990s  Acknowledging Subpoenas COURTS ACCEPT – Photocopies of ―original,‖ electronic source documents and records © 2007
  10. 10. 2010  Acknowledging Subpoenas COURTS ACCEPT – Secured electronic files of ―original,‖ electronic source documents and records – Hard copy computer printouts of ―original,‖ electronic source documents and records © 2007
  11. 11. 2010 Secured electronic files and hard copy computer printouts are admissible in court as long as the healthcare organization can substantiate – the trustworthiness of the system(s) used to store and retrieve the documents and records – the accuracy of the organization’s records management policies and procedures – the documents and records were not created just for a court case. It is important to verify the courts’ acceptance of digital records on a state-by-state basis. © 2007
  12. 12. 2010  Acknowledging the humungous number of other requests for Release of Information (RoI) / Disclosure of Information PATIENTS / ATTORNEYS / … ETC. – Demanding and, in most cases, entitled to ―any and all records‖ connected to an episode of care © 2007
  13. 13. No Longer Cardboard Boxes Organizational intranets and Web portals allowing designated Custodians of Records, RoI professionals, and even patients — after rigorous authorization and authentication processes — to  click on hyperlinks  instantaneously retrieve ―original‖ electronic source documents and objects required by subpoenas or other requests  securely transmit them to the requesters © 2007
  14. 14. Electronic Source Records  All related digital (electronic) patient financial records from financial data repositories © 2007
  15. 15. Electronic Source Records  All related digital (electronic) patient medical records from clinical data repositories, such as  acute care health records  ambulatory care health records  long-term care health record  mental health care records © 2007
  16. 16. Electronic Source Records  Includes all related:  Digital ―conversations,‖ including eMail messages, vMail messages, e- annotations (the equivalent of electronic Post-it notes), text messages, and digitized telephone consults © 2007
  17. 17. Electronic Source Records  Includes all related:  Digital diagnostic images from diagnostic image repositories, including digital X-rays as well as CT, MR, and nuclear medicine © 2007
  18. 18. Electronic Source Records  Includes all related:  Cine, including cardiac catheterization and ultrasound images (video files) from video repositories  Digital medical dictation (audio files) from audio repositories © 2007
  19. 19. Electronic Source Records  Includes all related:  Medical transcription (text files) from text repositories  Digital photographs, including those taken from pathology digital cameras-on-a-stick © 2007
  20. 20. Electronic Source Records  Includes all related:  Waveforms (signal trace or graphic files) from signal trace repositories, including ECGs, fetal traces, and output from other electronic, point- of-care medical devices © 2007
  21. 21. Electronic Source Records Handwritten Notes Laboratory Orders / Results and Drawings Orders / Medication Orders / MARsSigned Patient Online ChartingConsent Forms Original, and Analog Discrete, Documentation Documents- Structured Document Data Image Data Detailed Radiology Charges Reports Diagnostic Text Data CTTranscribed Image Data MR Reports Video Ultrasound Signal Nuclear Med UBs and Data Audio Tracing Itemized Bills Data Data Pathology Ultrasound and Images Cardiac Catheterization EKG/EEG/Fetal Examinations Heart Voice Dictations Monitoring Signal Sounds & Annotations Tracings © 2007
  22. 22. Electronic Health Records  Encompass health information recorded on any digital medium as read-only or rewritable formats – Magnetic tape / disk – WORM optical disk – CD / DVD © 2007
  23. 23. Electronic Health Records  Are evidence of transactions or events that – have legal or business value (i.e., the records reflect the business objectives of the organization, such as receiving reimbursement for services provided) – indicate an intention to be memorialized © 2007
  24. 24. Electronic Health Records =Business RecordsSubject to Evidentiary Discovery © 2007
  25. 25. Electronic Health Records =Not Business Records Reproductions of the electronic records that are provided by the organization to an individual or another healthcare organization for convenience purposes © 2007
  26. 26. Electronic Health Records =Not Business Records Ad hoc or draft electronic record documents, such as some eMail, some vMail, some eAnnotations, text messages, work sheets, work lists, works-in-progress, and database manipulations © 2007
  27. 27. Electronic Health Records =Not Business Records Personal Health Records (PHRs), which are patient owned, managed, and populated -- and might include copies of the healthcare organization’s business record files. © 2007
  28. 28. Caveat?  BUSINESS RECORDS IF  the records are subsequently used by the healthcare organization in evaluating or treating the patient, such as providing care, reviewing data, and documenting observations, actions, or instructions  FOR EXAMPLE  patient-owned, managed, and populated ―tracking‖ records, such as electronic medication tracking records, glucose and insulin tracking records, etc. © 2007
  29. 29. Caveat?  THE FEDERAL RULES OF CIVIL PROCEDURE GOVERNING ELECTRONIC DISCOVERY, effective December 1, 2006. For example: © 2007
  30. 30. Caveat?  Rule 26 – the Rule that describes the legal obligation to maintain and disclose relevant records – specifies that ―a party must now, without awaiting a discovery request, provide to other parties a copy of, or description by category and location of, electronically stored information‖. © 2007
  31. 31. Think About That …  Without awaiting a Discovery Request  Provide a Copy of, or Description by  Category And  Location Of  Electronically Stored Information  CAN YOU DO THIS NOW? © 2007
  32. 32. Electronic Records Management  The process by which electronic records are created and preserved for evidentiary discovery (i.e., legal / business) and, now, electronic discovery purposes © 2007
  33. 33. Electronic Records Management  Requires astute decision making throughout the life cycle of the electronic record © 2007
  34. 34. Electronic Record Decision Making What electronic records to keep? How long to keep? How to assign record authorities and responsibilities? How to design the process? How to administer the process? How to audit the process? How to review the process? © 2007
  35. 35. Electronic Record Life Cycle  Creating / Receiving  Indexing  Searching  Retrieving  Processing  Routing / Distributing  Storing  Maintaining  Securing  Purging / Archiving / Destroying © 2007
  36. 36. HealthElectronic ^ Records Management Example healthcare information systems capable of creating electronic records and then processing, distributing, maintaining, storing, retrieving, archiving, and destroying the records… © 2007
  37. 37. HealthElectronic ^ Records Management Patient billing and accounts receivable systems Healthcare information systems Clinical information systems © 2007
  38. 38. HealthElectronic ^ Records Management Cardiology, laboratory, radiology, and pharmacy information systems Picture Archiving and Communications Systems (PACS) © 2007
  39. 39. HealthElectronic ^ Records Management Digital dictation systems and speech recognition systems Word processing (i.e., transcription) systems © 2007
  40. 40. HealthElectronic ^ Records Management Electronic document management systems (EDMSs) Report, print, and output management systems (e.g., reproduction systems) © 2007
  41. 41. HealthElectronic ^ Records Management eMail systems (e.g., Microsoft Outlook) Collaboration systems (e.g., project extranets and online conferencing systems) © 2007
  42. 42. HealthElectronic ^ Records Management Dynamic Web site systems with online forms, transactions, and metadata © 2007
  43. 43. HealthElectronic ^ Records Management  It’s now time for healthcare organizations to address the new challenges involved in the ongoing maintenance and management of the EHR.  This requires:  management strategies  knowledge and leadership skills to shape and deploy the strategies © 2007
  44. 44. HealthElectronic ^ Records Management  Creating and maintaining EHR retention and disposition schedules based on administrative, legal, fiscal, and historical needs  Establishing documented procedures for the scheduled destruction of obsolete EHRs and retaining proof of such destruction  Developing, implementing, and maintaining efficient EHR filing systems  Quickly locating and organizing EHRs © 2007
  45. 45. HealthElectronic ^ Records Management  Training personnel in the use and function of EHR management processes  Ensuring the confidentiality, security, and integrity of the information contained in the EHRs  Monitoring / auditing the completeness and accuracy of the EHR content © 2007
  46. 46. Automated EHRM Functions  Record capture, where a predefined set of metadata is established supporting accurate representation of the record with disciplined disposition and retention actions  Record classification, where appropriate categories of records are established with applied rules © 2007
  47. 47. Automated EHRM Functions  Record preservation format, where a format, such as eXtensible mark-up language (XML) or portable document format (PDF), is established for retrieval and cross-departmental interchange  Record retention calculation, where ―triggers‖ automatically save electronic documents or Web content as records according to pre-established business rules © 2007
  48. 48. Automated EHRM Functions  Record disposition control, where rules provide electronic notifications to managers that certain records or documents have met their retention dates and require manual confirmation to delete, save, or destroy  Record deletion and destruction and suspension of record deletion and destruction to support litigation. © 2007
  49. 49. HealthElectronic ^ Records Management LONG TERM STRATEGIES  Develop a comprehensive plan for EHR life cycle management  Incorporate the plan into the organization’s IT strategic plan  Dictate the plan to the users © 2007
  50. 50. HealthElectronic ^ Records Management SHORT TERM PLANS  Develop EHR policy / procedure guidelines for existing information systems  Develop EHR policy / procedure guidelines before buying new EHR technologies / systems © 2007
  51. 51. HealthElectronic ^ Records Management• A ________ information system shall allow users to create folder hierarchies, wherein users can place electronic documents or records that contain PHI.• A ________ information system shall be capable of automatically applying classification and retention schedules that are established by the healthcare organization.• A ________ information system shall be capable of taking Web site snapshots, allowing users to record the sequence of the screens encountered during a Web site transaction. © 2007
  52. 52. HealthElectronic ^ Records ManagementTECHNICAL CONSIDERATIONS Identify all existing enterprise-wide repositories that securely store EHR records and documents which merit evidentiary discovery handling Move all inactive or semi-active files to separate, secure storage © 2007
  53. 53. HealthElectronic ^ Records ManagementTECHNICAL CONSIDERATIONS Implement a regular sweep of EHR information to ensure that the archive is kept accurate and up to date Trawl the archive and assign retention flags to information © 2007
  54. 54. HealthElectronic ^ Records ManagementTECHNICAL CONSIDERATIONS Destroy unflagged files from the archive Manage large files and file types for security purposes © 2007
  55. 55. HealthElectronic ^ Records Management COLLABORATION OF EXPERTS  Legal professionals  HIT professionals  HIM professionals  Risk / Compliance professionals  Clinical professionals © 2007
  56. 56. Questions & Answers dkohn@daksystcons.com www.daksystemsconsulting.com © 2007