Electronic Health Records Overview

Electronic Health Records & Ancillary Functions

• Electronic Health Records (EHRs) and ancillary functions of a health record are a significant topic.
• Incomplete and delinquent records are important to note, with various timeframes.
• Specialist roles, such as physicians, advanced practice registered nurses (APRNs), and physician assistants (PAs), are recognized and governed by standards.
• Medical staff bylaws and how they interrelate with health information management (HIM) are of importance.
• HIM responsibilities, such as managing deficiency software, are key.

Incomplete and Delinquent Records

• Timeframes for various medical records like history and physicals (H&Ps), operative reports (OP Reports), discharge summaries, and vital signs/test results (V/O & T/O) are determined by factors like state laws, and/or general rules.
• These guidelines are specific to situations like those related to urgent care, or where patients are seen by various providers.
• Timeframes for consents and autopsies are also defined, with provisional and final periods indicated.

Medical Staff Review

• The medical staff includes physicians, advanced practice registered nurses (APRNs), and physician assistants (PAs).
• The governing bodies for the medical staff, including chief medical officers (CMOs), CEOs, and boards of directors (BODs), are important considerations.
• Medical staff bylaws provide detailed structure, and how HIM professionals interact with the medical staff is related to these standards.

HIM Role

• HIM and medical staff interact. The medical staff must be aware of medical staff bylaws. HIM must be aware of medical staff bylaws.
• HIM's responsibility, including deficiency software, is reviewed.

Incomplete Record Control - Quantitative Analysis

• This method analyzes records for completeness.
• Discharge, chart, and deficiency analyses are included.
• The purpose is to ensure 100% of records have complete information.
• This analysis is usually retrospective and can also be concurrent.

Incomplete Record Control - Steps in Quantitative Analysis

• Crucial steps like checking for missing documents and authentications for each provider are essential.
• This includes the need for all forms and entries to be authenticated.
• Recording deficiencies with specific software dedicated to monitoring them is crucial.

Examples of Complete Documentation

• Forms, documents, and consents must be signed.
• Orders, including medications, dosages, frequencies, routes, and durations, need details.
• Vital signs must be documented.
• Patient name and medical record number (MRN) must be present on all forms.
• Discharge summaries must be completed.

Incomplete Record Control - Qualitative Analysis

• This analysis reviews the quality and adequacy of documentation.
• It's used to evaluate if documentation policies are followed and if licensure, regulations, and accreditation standards are adhered to.
• This review often delves beyond individual physician records and addresses timeliness, legibility, and thoroughness in documenting.
• Qualitative analysis can be concurrent, retrospective or use open record review, or point-of-care review, or continuous review. These approaches reflect different methodologies during the process.

Examples of issues which may be found in Qualitative analysis of records.

• Legible writing is essential in medical records. Use of approved abbreviations is necessary. Data must be followed up with the provider if additional orders are needed.

Incomplete vs. Delinquent Records

• Incomplete records are deficient records that are not finished within a timely manner within the time frame established by an organization.
• Completion times begin at the moment of discharge or a specific event.
• Medical staff create and establish the timing guidelines for medical records completion.
• Delinquent records occur when records haven't been completed within the established time frame set by the facility, organization or licensing board. An example of a Joint Commission timeframe is 30 days post discharge, and hospital records may be 14 days post discharge or other specified time period.

Delinquent Records (Continued)

• The number of delinquent records cannot exceed 50% of the average number of discharges in some facilities or organizations.
• Open record reviews are helpful in identifying and addressing missing signatures and ensuring timely documentation, especially on progress notes and orders.

Examples- Additional Notes

• A sample specific case of a patient involves a physician giving a V/O in March for a patient who was discharged in March. There are 30 days for the V/O to be completed according to Kentucky law.
• Penalties for delinquent records are enforced, and may include temporary suspension from the medical staff.
• If an individual remains suspended from the medical staff for over 30 days, then there may be implications which include reporting to the National Practitioner Database and state medical boards.

Notification of Physicians

• Different notification methods exist, such as reminders, warning letters, suspension letters, and dismissal letters.
• First-level notice is often a weekly reminder for needed records.
• Formal notification levels include a warning letter, and a suspension letter.
• Finally, dismissal letters for complete revocation from the medical staff.

Electronic Health Records: Why Convert?

• The shift to electronic health records (EHRs) is significant, with noted reasons like decreasing medical errors, improving savings, increased communication, preventing misfiled or lost documents, ensuring better documentation, and improving legibility among other benefits.
• The 1999 report by "To err is Human" noted between 44,000 to 98,000 medical errors in a year.
• There are current cost savings from converting to EHRs.

Definitions

• EHRs are records that can be shared among authorized entities in a computerized format.
• EMRs are computer-based records for a single patient at an organization.
• PHR is a personal health record (computerized or paper-based) managed by an individual for information about themselves.
• Health information technology (HIT) is used for technology management of patient healthcare information.

Systems Working Together

• Interoperability is a key concept, meaning different systems can share information.

Various Applications of an EHR

• EHRs have many applications, covering administrative functions, ancillary clinical records (like lab and radiology reports, Picture Archiving and Communication Systems (PACS)) clinical sections (like emergency department (ED), surgery, labor and delivery (L&D), nursing notes, and histories and physicals (H&Ps)) and financial data.

Administrative and Financial Applications

• Patient demographics, medical record numbers (MRNs), visits, encoding, natural language processing (NLP), and computer-assisted coding (CAC) support these applications.
• The processes of transcription, billing, chart deficiency management, and quality improvement (QI) are also relevant.
• HIM professionals' roles in these areas, including RHIA and RHIT distinctions, are also considered.

Natural Language Processing (NLP)

• NLP refers to computational techniques, text mining, algorithms, and statistical methods used to convert unstructured data into structured data.
• This technology is sophisticated enough to understand spoken word and classify them appropriately (e.g. for ICD-10 coding).
• NLP is relevant because healthcare data includes variations in word-usage, and natural language.

Computer Assisted Coding (CAC)

• CAC employs NLP to scan medical records, identifying relevant codes.
• Benefits such as improved productivity and consistency are associated with this method.
• Challenges, including costs, potential errors, and a lack of uniformity in standards, are discussed.

Core Clinical Applications

• Results management, point-of-care documentation, medication management of provider order entries (eMAR, e-RX), the use of systems like Pyxis, messaging, and clinical decision support (CDS) are important.

Ancillary Clinical Applications

• EHRs include ancillary records like lab reports, radiology (imaging), picture archiving and communications system (PACS), pharmacy records, and dietary documentation.

Connecting Patients

• Patient portals (e.g. MyChart) and personal health records (PHRs) are discussed to aid communication between patients and providers.
• PHR may be paper or electronic, connected to a provider's electronic medical record or separate from provider records.

Information Portability

• Information can be portable via iPads, smart phones.
• Security of mobile health is important.

Changing HIM with EMR

• HIM activities, like file room activities, releasing information, completing charts, chart review, coding, abstracting, billing, and transcription and documentation imaging, change in the EMR era.