Data Analytics and Information Governance - Task 3
Hybrid medical record systems pose many challenges for the HIM professional. First, I will discuss some of the strengths of hybrid medical records fallowed by some of its weaknesses.
Paper records and forms in a hybrid record system have some advantages. It takes little to no training for doctors and staff to understand how to complete a paper record. In addition, the contrast of ink on paper and handwriting make it is easier to validate the authorship and originality of paper records.
However, hybrid records can pose many disadvantages. The paper portion of a hybrid record can only be accessed/possessed by one provider at time. Providers who lack access to all of the patient's information …show more content…
This includes any outside vendors such as disposal companies. The Willow Bend policy should include verbiage requiring vendors to enter into a business associate agreement and certify that any employees handling PHI have appropriate HIPAA and privacy training (45 CFR 160.103) (U.S. Department of Health and Human Services, Office for Civil Rights, n.d.).
Willow Bend vs. Medicare
Medicare rules regarding record maintenance and destruction are long and complex. The Willow Bend policy does not delineate Medicare records from any others. This could lead to records being destroyed that violate Medicare's conditions for participation. Examples of potential deficiencies in Willow Bend's policy are as follows:
1) Medicare requires that scanned/imaged medical records are visually compared and certified as an exact copy, within 30 days. Willow Bend's current policy (I.(b)) implies that once a document has been converted (scanned) into an electronic format; records are transferred to the medical record "without manual intervention". This may run contrary to Medicare's requirements (Centers for Medicare Services [CMS], 2015, p. …show more content…
Willow Bend vs. State of Utah
For the most part, Willow Bend's policy meets most of the requirements of Utah State law regarding medical record retention and disposal. There are two areas where Willow Bend's policy should be amended to bring it into full compliance with state regulations.
1) Utah Law (R432-150-25(2)(b)) Requires, at a minimum, that the facility review its practices with a Registered Record Administrator or an Accredited Record Technician no less than semi-annually. Willow Bend should write this into its policy or clarify that the Health Information Management Department Director holds these credentials.
2) The State of Utah does not distinguish between medical records and diagnostic images (R432-150-25 (4)(m)). Willow Bend's policy allows the destruction of diagnostic images after five years. However, the State of Utah would consider this a violation of its seven-year retention rule (Utah Department of Administrative Services Division of Administrative Rules,
Hybrid medical record systems pose many challenges for the HIM professional. First, I will discuss some of the strengths of hybrid medical records fallowed by some of its weaknesses.
Paper records and forms in a hybrid record system have some advantages. It takes little to no training for doctors and staff to understand how to complete a paper record. In addition, the contrast of ink on paper and handwriting make it is easier to validate the authorship and originality of paper records.
However, hybrid records can pose many disadvantages. The paper portion of a hybrid record can only be accessed/possessed by one provider at time. Providers who lack access to all of the patient's information …show more content…
This includes any outside vendors such as disposal companies. The Willow Bend policy should include verbiage requiring vendors to enter into a business associate agreement and certify that any employees handling PHI have appropriate HIPAA and privacy training (45 CFR 160.103) (U.S. Department of Health and Human Services, Office for Civil Rights, n.d.).
Willow Bend vs. Medicare
Medicare rules regarding record maintenance and destruction are long and complex. The Willow Bend policy does not delineate Medicare records from any others. This could lead to records being destroyed that violate Medicare's conditions for participation. Examples of potential deficiencies in Willow Bend's policy are as follows:
1) Medicare requires that scanned/imaged medical records are visually compared and certified as an exact copy, within 30 days. Willow Bend's current policy (I.(b)) implies that once a document has been converted (scanned) into an electronic format; records are transferred to the medical record "without manual intervention". This may run contrary to Medicare's requirements (Centers for Medicare Services [CMS], 2015, p. …show more content…
Willow Bend vs. State of Utah
For the most part, Willow Bend's policy meets most of the requirements of Utah State law regarding medical record retention and disposal. There are two areas where Willow Bend's policy should be amended to bring it into full compliance with state regulations.
1) Utah Law (R432-150-25(2)(b)) Requires, at a minimum, that the facility review its practices with a Registered Record Administrator or an Accredited Record Technician no less than semi-annually. Willow Bend should write this into its policy or clarify that the Health Information Management Department Director holds these credentials.
2) The State of Utah does not distinguish between medical records and diagnostic images (R432-150-25 (4)(m)). Willow Bend's policy allows the destruction of diagnostic images after five years. However, the State of Utah would consider this a violation of its seven-year retention rule (Utah Department of Administrative Services Division of Administrative Rules,