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From Paper to Data: Changing Roles and Functions California Institute of Mental Health Jill Burrington-Brown, MS, RHIA, FA...
Manage Information, Not Paper <ul><li>Move away from moving paper to understanding information process </li></ul><ul><li>U...
Manage Information <ul><li>Move away from moving paper to understanding information process </li></ul><ul><ul><li>Understa...
Understand and Fix Current Processes <ul><li>Current processes – whether paper-based or electronically enhanced –  </li></...
Old Flow Process Still Works!
Candidates for Re-design <ul><li>Access to charts (e.g., document imaging) </li></ul><ul><li>Results retrieval (e.g., phys...
Legal EHR <ul><li>True or False? </li></ul><ul><li>If you implement a EHR, you will automatically have a legal health reco...
Definition of L-EHR <ul><li>The legal EHR is a subset of the entire patient database. </li></ul><ul><li>The roles of the l...
Defining YOUR L-EHR <ul><li>What legal entities enforce regulations, guidelines, standards or laws? </li></ul><ul><li>Dete...
You should consider: <ul><li>Alerts, Reminders and Pop-ups </li></ul><ul><li>Continuing Care Records </li></ul><ul><li>Dat...
What is NOT included <ul><li>Administrative Data </li></ul><ul><li>Derived Data </li></ul>
Electronic Discovery Rule <ul><li>Took Effect December 1, 2006 </li></ul><ul><li>Federal Rules of Civil Procedure </li></u...
Key Issues Related to Health Information Management <ul><li>Discovery and Disclosure </li></ul><ul><li>Processes to addres...
Key Issues Related to Health Information Management <ul><li>Retention and Destruction </li></ul><ul><li>Where is our infor...
Key Issues Related to Health Information Management <ul><li>Legal Hold  </li></ul><ul><li>Issued by the Court if there is ...
Key Issues Related to Health Information Management <ul><li>Spoliation </li></ul><ul><li>Intentional destruction, mutilati...
Key Issues Related to Health Information Management <ul><li>Disaster Recovery:  Two Key Goals </li></ul><ul><li>Preservati...
Developing Policies and Procedures <ul><li>Locate, review and/or develop policies on: </li></ul><ul><ul><li>Definition of ...
Review, Revise and Monitor <ul><li>References: </li></ul><ul><li>AHIMA e-HIM Work Group on e-Discovery. &quot;New Electron...
References <ul><li>Scholtes, Peter R, et al.  The Team Handbook , 3 rd  Edition.  Oriel Incorporated.  2003 </li></ul><ul>...
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Burrington-Brown, Premeau - Changing Approach to Oversight of ...

  1. 1. From Paper to Data: Changing Roles and Functions California Institute of Mental Health Jill Burrington-Brown, MS, RHIA, FAHIMA
  2. 2. Manage Information, Not Paper <ul><li>Move away from moving paper to understanding information process </li></ul><ul><li>Understand your processes </li></ul><ul><li>Understand the Legal EHR </li></ul><ul><li>Understand New Discovery Rules for Electronic Records </li></ul>
  3. 3. Manage Information <ul><li>Move away from moving paper to understanding information process </li></ul><ul><ul><li>Understand how information is created </li></ul></ul><ul><ul><li>Understand how information is stored </li></ul></ul><ul><ul><li>Understand how information is used </li></ul></ul>
  4. 4. Understand and Fix Current Processes <ul><li>Current processes – whether paper-based or electronically enhanced – </li></ul><ul><ul><li>Have faults </li></ul></ul><ul><ul><li>Use workarounds </li></ul></ul><ul><ul><li>Are not understood </li></ul></ul><ul><li>Automating a bad process only makes it worse </li></ul><ul><li>Automation creates change – or there would be no value </li></ul><ul><ul><li>Accept a degree of change </li></ul></ul><ul><ul><li>Support “good” processes </li></ul></ul>
  5. 5. Old Flow Process Still Works!
  6. 6. Candidates for Re-design <ul><li>Access to charts (e.g., document imaging) </li></ul><ul><li>Results retrieval (e.g., physician portal, PACS) </li></ul><ul><li>Order entry (e.g., CPOE, e-Rx) </li></ul><ul><li>Productivity (e.g., in-basket) </li></ul><ul><li>Charting (e.g., BC-MAR, V/S, templates) </li></ul><ul><li>Patient support (e.g., way finding, scheduling, education, CCR, PHR) </li></ul><ul><li>Evidence-based medicine (e.g., CDR, CDW, CDSS) </li></ul>
  7. 7. Legal EHR <ul><li>True or False? </li></ul><ul><li>If you implement a EHR, you will automatically have a legal health record. </li></ul>
  8. 8. Definition of L-EHR <ul><li>The legal EHR is a subset of the entire patient database. </li></ul><ul><li>The roles of the legal health record: </li></ul><ul><li>Support decisions made in a patient’s care </li></ul><ul><li>Support the revenue sought from payers </li></ul><ul><li>Document the services provided as legal testimony </li></ul>
  9. 9. Defining YOUR L-EHR <ul><li>What legal entities enforce regulations, guidelines, standards or laws? </li></ul><ul><li>Determine whether the records are created in the ordinary course of business </li></ul><ul><li>Create matrix that defines each data element. </li></ul>
  10. 10. You should consider: <ul><li>Alerts, Reminders and Pop-ups </li></ul><ul><li>Continuing Care Records </li></ul><ul><li>Data from Source Systems </li></ul><ul><li>Downtime procedures </li></ul><ul><li>Personal Health Records </li></ul>
  11. 11. What is NOT included <ul><li>Administrative Data </li></ul><ul><li>Derived Data </li></ul>
  12. 12. Electronic Discovery Rule <ul><li>Took Effect December 1, 2006 </li></ul><ul><li>Federal Rules of Civil Procedure </li></ul><ul><li>Rules 16, 36, 33, 34, 37 </li></ul>
  13. 13. Key Issues Related to Health Information Management <ul><li>Discovery and Disclosure </li></ul><ul><li>Processes to address pretrial conferences </li></ul><ul><li>Understand location of data </li></ul><ul><li>Understand differences between: </li></ul><ul><ul><li>Legal Health Record </li></ul></ul><ul><ul><li>Business Record </li></ul></ul><ul><ul><li>Designated Record Set </li></ul></ul>
  14. 14. Key Issues Related to Health Information Management <ul><li>Retention and Destruction </li></ul><ul><li>Where is our information? </li></ul><ul><li>What are our routine practices for: </li></ul><ul><ul><li>old back up tapes </li></ul></ul><ul><ul><li>instant messages </li></ul></ul><ul><ul><li>voice mail </li></ul></ul><ul><ul><li>shadow records </li></ul></ul>
  15. 15. Key Issues Related to Health Information Management <ul><li>Legal Hold </li></ul><ul><li>Issued by the Court if there is belief it might be destroyed. Suspends the normal disposition procedure. </li></ul><ul><li>It can be issued at any time in the process. </li></ul><ul><li>Develop policy </li></ul>
  16. 16. Key Issues Related to Health Information Management <ul><li>Spoliation </li></ul><ul><li>Intentional destruction, mutilation, alteration or concealment of evidence. Organization will have to show that information lost was a result of a good faith operation of an electronic system. </li></ul>
  17. 17. Key Issues Related to Health Information Management <ul><li>Disaster Recovery: Two Key Goals </li></ul><ul><li>Preservation of Patient Records </li></ul><ul><li>Return of healthcare facility to normal operations as quickly as possible. </li></ul>
  18. 18. Developing Policies and Procedures <ul><li>Locate, review and/or develop policies on: </li></ul><ul><ul><li>Definition of legal health record, retention, destruction, and electronic management. </li></ul></ul><ul><ul><li>Responding to subpoenas, court orders, or requests from attorneys. </li></ul></ul><ul><ul><li>Education of staff, employees and clinicians on proper processes. </li></ul></ul>
  19. 19. Review, Revise and Monitor <ul><li>References: </li></ul><ul><li>AHIMA e-HIM Work Group on e-Discovery. &quot;New Electronic Discovery Civil Rule.&quot; Journal of AHIMA 77, no.8 (September 2006): 68A-H. Found at: http://tinyurl.com/m9fuf </li></ul><ul><li>AHIMA e-HIM Work Group on the Legal Health Record. &quot;Update: Guidelines for Defining the Legal Health Record for Disclosure Purposes.&quot; Journal of AHIMA 76, no.8 (September 2005): 64A-G. Found at: http://tinyurl.com/nb83j </li></ul>
  20. 20. References <ul><li>Scholtes, Peter R, et al. The Team Handbook , 3 rd Edition. Oriel Incorporated. 2003 </li></ul><ul><li>AHIMA Practice Briefs </li></ul><ul><li>Found at: www.ahima.org </li></ul>

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