Hybrid Health Record
Running head: Hybrid Health Record
Hybrid Health Record
Ryan Engle 250129
Western Governor’s University
Abstract
Management of health records is becoming increasingly complex. I will discuss the management of “Hybrid” health records, including legal issues. Additionally, I will evaluate a sample record policy for compliance with Washington State Administrative Code, Medicare Conditions of Participation, and Health Insurance Portability and Accountability act.
Hybrid Health Record
Electronic Health Records (EHR) transition from paper to electronic has necessitated a “hybrid” environment. The combination of paper, EHR, and document imaging (scanning) is causing challenges for Health Information Managers (HIM). Paper forms are still utilized by some Healthcare Providers due to necessity or due to limitations of the EHR. Practitioners must be able to access and input information into an EHR or onto a form that will be later scanned into the EHR, and that information must meet legal requirements.
There are many strengths noted in utilizing a Hybrid EHR. Hybrid records allow for paper and electronic records to be accessed by multiple practitioners at the same time. These also allow for the Health Records Technician to ensure that the legal requirements of the EHR are met. Ensuring that practitioners can access lab results, radiology reports, previous notes from other visits, sending and receiving notes from outside referrals and other functions make Hybrid records valuable to the Health Providers.
Some of the weaknesses of the Hybrid EHR become apparent only when actually implementing the process. When a document is scanned into the record, the HIM staff must ensure a crosswalk is created. Crosswalks are structures within the EHR that include headings, such as “Discharge Documents”, and subheadings that are useful such as “Discharge Instructions”, “Discharge Summaries” or “Admission Information”. These crosswalks allow for a practitioner to access
Hybrid Health Record
Ryan Engle 250129
Western Governor’s University
Abstract
Management of health records is becoming increasingly complex. I will discuss the management of “Hybrid” health records, including legal issues. Additionally, I will evaluate a sample record policy for compliance with Washington State Administrative Code, Medicare Conditions of Participation, and Health Insurance Portability and Accountability act.
Hybrid Health Record
Electronic Health Records (EHR) transition from paper to electronic has necessitated a “hybrid” environment. The combination of paper, EHR, and document imaging (scanning) is causing challenges for Health Information Managers (HIM). Paper forms are still utilized by some Healthcare Providers due to necessity or due to limitations of the EHR. Practitioners must be able to access and input information into an EHR or onto a form that will be later scanned into the EHR, and that information must meet legal requirements.
There are many strengths noted in utilizing a Hybrid EHR. Hybrid records allow for paper and electronic records to be accessed by multiple practitioners at the same time. These also allow for the Health Records Technician to ensure that the legal requirements of the EHR are met. Ensuring that practitioners can access lab results, radiology reports, previous notes from other visits, sending and receiving notes from outside referrals and other functions make Hybrid records valuable to the Health Providers.
Some of the weaknesses of the Hybrid EHR become apparent only when actually implementing the process. When a document is scanned into the record, the HIM staff must ensure a crosswalk is created. Crosswalks are structures within the EHR that include headings, such as “Discharge Documents”, and subheadings that are useful such as “Discharge Instructions”, “Discharge Summaries” or “Admission Information”. These crosswalks allow for a practitioner to access
References: Centers for Medicare and Medicaid Services. (2010). Medical Record Retention and Media Formats for Medical Records. Available: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1022.pdf. Last accessed 4th Oct 2012. Hamilton, W., Round, A., Sharp, D., & Peters, T. (2003). The quality of record keeping in primary care: a comparison of computerised, paper and hybrid systems... including commentary by Sterne JAC. British Journal Of General Practice, 53(497), 929-933. Latour, K (2010). Health Information Management. 3rd ed. Chicago: AHIMA. 189-206. Mitchell, R. (2011). Hybrid Medical Records are Here to Stay. Available: http://fortherecordmag.com/archives/013111p20.shtml. Last accessed 4th Oct 2012. Pizzi, Richard. (2007). "Hybrid" Medical Records an Option for Some Hospitals. Available: http://www.healthcareitnews.com/news/hybrid-medical-records-option-some-hospitals. Last accessed 4th Oct 2012.