When one thinks of “medical records,” it brings up images of thick file folders filled with documents and a physician’s chicken scratch on scraps of paper. In reality, working in medical records requires knowledge and skill in several functions. As custodian of the healthcare organization’s legal medical record, in some instances, Health Information Management professionals are considered “The Chart Police.” These are the professionals who monitor and audit access to patient records, assure data integrity, make chart corrections when required, and assure that records are kept in a manner that is in compliance with government and regulatory agencies.
An HIM analyst works in concert with the HIM operations staff to assure that patient documentation adheres to organizational and regulatory standards. HIM is a hub of activity that intersects with internal and external legal entities, compliance professionals, healthcare administrators, patients, government agencies, and, in some cases, research organizations. Impermissible disclosure of a patient’s record can have legal and financial ramifications for an organization that is not careful in its handling of its patient records.
HIM And Protected Health Information
To help healthcare organizations meet the needs of the people and organizations requiring access to patient records, an HIM analyst supports a healthcare organization’s management of protected health information (PHI), which in turn affects reimbursement for services and pays the salaries of employees of the organization. PHI comes in many forms and by employing HIPAA compliant methods of storage and retrieval, HIM professionals guard against identity theft and inappropriate disclosure. The HIM analyst must know what comprises an accurate record of a patient’s medical history at a given organization. In the era of the electronic health record (EHR), the analyst should also be aware of what is lawful and necessary when sharing patient information between organizations.
Document Management Systems
Document management is a big responsibility for an HIM department, whose responsibility covers documentation of a patient’s visits, which can include transcribed/ dictated documents, scanned documents, handwritten notes, images, files, and health records from outside facilities. Document management can be accomplished with a combination of a document management system (DMS) and Binary Large Object (BLOB) storage. In some instances, the DMS will hold scanned images limited to JPG, TIFF, and PNG files, all formats available for scanned documents. The BLOB storage can house documents in PDF, HTML, WAV, and MP4 files. Some EHRs have their own DMS, and others are integrated with third-party systems. Any DMS considered for third-party integration should be HIPAA-compliant, able to store patient records in a secure manner, and made available to an end user only when that user is authorized to access patient records in the course of their job responsibilities. Whether the document is stored via BLOB or DMS, it is accessible by the EHR through an image viewer which allows a user to click a hyperlink in the EHR and launch the image from the storage system.
Managing The Patient Record
One method employed to manage the patient record is for the department to track and document when a visit, surgery, consult, or hospital admission takes place, and when providers complete the documentation. For example, a document called a History and Physical (H&P) must be on a patient’s chart before a scheduled surgery begins. If the H&P is not in place, the provider cancels or reschedules the surgery. A patient’s chart undergoes review for accurate documentation every time they are admitted to or has a procedure complete in a healthcare facility through a process called deficiency tracking. In the previous example, a missing H&P would render the chart deficient. A provider completes documentation, and signs that document electronically, with a date and time stamp, to meet legal and regulatory standards set. It is important that these e-signatures appear with a date and time stamp to remain in compliance and to be considered eligible for inclusion in the legal medical record.
Once a hospital discharges a patient, documentation of the discharge status is necessary and occurs in a timely manner. Again, on review of the chart, when this documentation does not exist, the chart is once again deficient. If a provider fails to properly sign and date his treatment of a patient, he or she the state’s medical board is notified, as large-scale failure of providers to document properly and timely could affect a healthcare organization’s accreditation status.
In the HIM analyst’s repertoire is the ability to support the function of documenting patient records, which requires construction and management of document types, distinguishing between transcribed and scanned documents, and assisting non-HIM professionals in the use of HIM-related functionality.
Healthcare IT Policy – HITECH Act, Meaningful Use, 21 Century Cures Act
Read More (not as boring as it sounds)
Release Of Information
While proper documentation of a patient’s visits and admissions is important, it is also important to avoid improper disclosure of patient records. The Release of Information staff is aware of what is eligible for release, and the proper steps to take prior to releasing information to the patient, a patient’s guardian, an insurance company, an attorney, or a government agency. To support this functionality, an HIM analyst, with input from the HIM Operations leadership/management, defines the legal medical record, setting the framework for the items released from patients’ charts in a uniform manner, by standardizing and avoiding the possibility of users guessing as to what is eligible for release. If any legal action is taken due to what has been released in the legal medical record, HIM employees (the custodian of the LMR) will be the person representing the releasing organization in court.
Release of information is where guarding PHI requires additional caution, as there are sometimes special circumstances surrounding a patient’s records. For example, a patient may be an employee of the healthcare organization. Other special circumstances requiring additional guardrails for PHI include when a person is in custody of law enforcement, someone is a crime victim, the patient is recognized as a VIP due to some form of notoriety, or even when the patient requests special handling. In these cases, an additional layer of security called “break-the-glass” may be deployed, requiring the user to document why they are accessing the records and to enter some sort of identifier (a username and password usually) to gain access to the records. This measure is to prevent impermissible access to PHI and is auditable should the need arise. If a user is notified that they are about to break the glass, even these interactions are auditable. Such events are labeled “bump the glass.”
HIM Coding
Release of information and deficiency tracking are only two ways HIM employs a patient’s records. Coding, or documenting the diagnoses and procedures that take place during a patient’s admission or visit to an outpatient setting. To support coding, the HIM analyst assures the annual updates of regulatory ICD-10 and PCS codes and administers any third-party encoder used to complete coding workflows. An HIM analyst works across the disciplines of document management/creation and finance, as coding depends on accurate documentation, which affects reimbursement for services, and influences the financial health of an organization.
Hand-in-hand with coding are clinical documentation integrity and auditing. This task verifies that documentation is accurate, concise, and relevant. Documentation reviewed includes items like left/right designations for surgeries, clarity of a provider’s written documentation of a procedure performed, and whether assignment is associated with the correct provider when documenting a completed procedure. Audits and CDI reviews assure correct documentation of admissions and visits, and that coders avoid “over coding,” which means assigning a higher-value diagnosis or procedure code than supported by the documentation in the patient’s chart. This function is necessary to avoid paying high fines or losing accreditation. These twin functions may be managed in a third-party application, also supported by the HIM analyst.
Chart Auditing
Though the above functions pose a challenge for most, the HIM analyst supports systems that manage patient identity, data integrity, and chart correction. With each of these disciplines, end-user education is quite important, as one can avoid a number of issues relating to mistakes in documentation, registration of patients, and misnaming or misidentifying patients, by carrying out workflows in the way defined by the system. This requires that the HIM analyst be aware of the numerous ways to navigate a patient’s electronic health record and the number of tools required for making corrections. Especially valuable to an HIM analyst is the ability to build relationships across disciplines, as corrections may have to occur in other systems interfaced to the EHR and other analyst teams may be involved.
In addition to providing technical support to users of an EHR, the HIM analyst should be prepared to train users in many scenarios, whether virtually, in person, or with tip sheets and quick-start guides.
How I Became An HIM Analyst
To get personal, I came to the HIM discipline as a medical transcriptionist, also known as a medical language specialist. With an undergraduate degree in journalism and a deep interest in medicine and technology, that job was a perfect fit, especially since I was able to use copy-editing skills and correct the grammar and punctuation of physicians. While working as an MT, I used every opportunity to learn the system I was using, making sure I knew how to fix issues that occurred often as we worked remotely, including connectivity, memory, formatting, transmissions, and archiving. This led to me creating instructional documents for my colleagues, teaching them how to avoid viruses and malware, and making presentations on how they could manage their own systems and avoid a call to the service desk.
After doing these tasks in addition to meeting and exceeding my MT goals, I had the opportunity to test implementation of new systems, and assisting with the system upgrades, working with vendors and the HIM Department management. Successfully completing additional tasks led to a phone call to interview for a job that changed my career track and put me on the path to becoming an HIM analyst. For people who ask how to get the opportunity to do what I do for a living, I offer the following advice:
- No task is too small or insignificant. Taking a moment to help someone lets you build relationships. See the person in front of you as a person and not a problem to solve.
- Nearly every opportunity is a learning opportunity. Consider frustrations and issues as building blocks. You may not use the skill you learn today, but eventually it will come in handy.
- Even if it’s “not your job,” take the opportunity to help your customer or a colleague.
- Keep your eyes open. Look for opportunities to enhance your skills, whether by taking additional classes, or shadowing someone who does the job you would like to do.
- READ and LISTEN. Technical manuals, web sites, magazines, blogs and podcasts can keep you informed of where technology is going in your area of interest.
- Be curious. Never stop asking questions, look for the cause and effect, and the correlation.
Denise Jerrido is a Health Information Management Systems Analyst who wanted to be a poet or a journalist, but found computers to be more interesting.
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