11/8/05
Transforming Health Record Management: A Strategic Role for HIM Professionals
Leslie Ann Fox, MA, RHIA, Patty Thierry Sheridan, MBA, RHIA, CCS
Thank you to Advance Magazine for permission to use this article

Patty: In the rush of excitement as the health care industry drives toward a national health information infrastructure, electronic health records (EHRs), personal health records (PHRs) and the many benefits of a health information technology revolution, new issues in electronic health records management (EHRM) have emerged that require the immediate attention and expertise of HIM professionals. As custodians of the physical medical record, HIM professionals are regarded as the experts in the creation, storage, retrieval, retention and destruction of paper health records. Leveraging that experience and knowledge is essential to leading the transition to EHRM, which is revolutionary, and a significant record management paradigm shift.

Leslie: I couldn’t agree with you more. It’s another transformative aspect of EHRs. Every aspect of basic record management requires new ways of thinking. Traditionally, HIM concerned itself with the paper record, usually inpatient and emergency department records and the physical location of those records. Perhaps it also had some responsibility for outpatient clinic records, X-ray film storage and retrieval as well. And maybe even responsibility for fetal heart monitor management.

Today, digitized (electronic) medical records are virtually everywhere throughout an organization. This most often includes data created by clinical department information systems such as cardiology and radiology information systems, by EHR component documentation modules and/or digitized documents that were once paper-based but have been scanned into a document imaging system. These digitized records should meet the same records management requirements of their paper counterparts and be part of a broader EHRM program led by HIM professionals.

Patty: That is a great vision Leslie. HIM professionals must lead their organizations in the development of policies and procedures that drive EHRM standards related to data completeness and accuracy, record location, record access, retention, disposition and record deletion and destruction. Before we go much further in this discussion, let’s take a minute to explain EHRM more fully as defined by the American Health Information Management Association (AHIMA) in its recently released e-HIM™ practice standard called “The Strategic Importance of Electronic Health Records Management.”

Leslie: Good idea. AHIMA defines EHRM as “the process by which electronic (e.g., digital) health records are created or received and preserved for evidentiary (e.g., legal or business) purposes. EHRM requires decision making and planning throughout the entire life cycle of the EHR from planning, processing, distribution, maintenance, storage and retrieval of the health record to its ultimate disposition, including archiving or destruction.”

Patty: The practice standard also points out that technology has made it possible for health records to include so much more than the traditional discharge summary, progress notes, physician orders, etc. It now comprises e-mail and voice messages containing protected health information, video files from cardiac catherizations and digital photographs from the wound clinic, for example. The handling of this information needs to be spelled out in an EHRM program.

Leslie: This is a very strategic role for HIM professionals. It’s a chance to demonstrate expertise in an area where HIM professionals have a tremendous passion. HIM professionals can start by creating awareness of the concept of EHRM and what it includes, and the importance of an EHRM strategy as part of an EHR roll-out. The topic of records management should be of particular interest to attorneys, information system professionals and risk managers. As with anything EHR related, developing record management practices should be a collaborative process.

Patty: Armed with information about EHRM from AHIMA’s body of knowledge, HIM professionals have a window of opportunity to raise awareness in their organization on the need for records management procedures and to lead the EHRM initiative.

Leslie: EHRM policies and procedures should be developed in concert with the implementation of the EHR. Organizations often implement the EHR and or departmental clinical systems without records management standards for storage, access, retention and destruction of data, leaving the facility vulnerable to legal issues or inefficiencies.

Patty: That’s true. In fact, it’s often an afterthought or something that is stumbled upon while figuring out how to integrate disparate clinical systems into the EHR or to make these systems available via a portal. And it is common with some EHR components such as nursing notes or lab results to require printing of these documents as a means of storing them because of the lack of an EHRM strategy.

Leslie: Oh yes, my favorite example, implementing a nursing documentation system only to end up producing more paper than ever before.

Patty: It’s a good idea to begin the EHRM process by doing an inventory of current information systems, particularly those that might be required to provide data for evidentiary purposes. Once an inventory has been taken, decisions need to be made on standardizing retention and destruction. Inevitably, through the inventory process, a wide range of record management procedures or lack thereof will be identified.

Leslie: As hospital organizations embark on their EHR journey, they quickly come to realize that there are a number of clinical department systems whose data doesn’t necessarily become part of an integrated EHR yet is part of the legal record. The same systems rarely have EHRM processes.

Patty: Yes that is so true. Outpatient departments in particular often have proprietary systems that don’t interface with an EHR. For example, clinical repositories can often be found in departments such as radiation oncology, pacemaker clinic, cardiac catherization laboratory, pediatric clinic, sleep study programs, pulmonary and cardiology rehabilitation departments, just to name a few.

Leslie: That’s a good list! I would add cardiology to the list as well because cardiology information systems create text along with images, waveforms and videos.

Patty: And let’s not forget about diagnostic images from picture archiving computer systems (PACS) as another clinical system where digitized images can be located.

Leslie: Managing clinical departmental repositories has traditionally been the responsibility of the clinical departments and will most likely continue as such. But in an EHR environment, these repository systems need to conform to EHRM standards regarding data creation, integrity storage, access, retention, archiving and destruction.

Patty: That brings us to the importance of building a plan for EHR life cycle management as discussed in the practice standard. Just because the record is in an electronic format doesn’t mean everything must be retained. The concept of selective destruction should be applied in the electronic environment as it would in a paper environment.

Leslie: What is this concept exactly?

Patty: It’s the practice of retaining specific documentation while destroying other types of documentation. For example, the AHIMA practice standard suggests that once the statute of limitations has expired on an episode of care, an organization may choose to retain key documents such as discharge summary, operative reports, pathology report and other diagnostic data, but destroy the rest of the electronic record for that episode. Ideally this is an automated process managed by business rules, which triggers retention and destruction.

Leslie: I am not sure how I feel about this concept with respect to the longitudinal record and consumer informatics. It makes sense to look at non-essential documentation that doesn’t add value after a defined period of time. I suspect that information important to the patient’s history will be contained in the personal health record (PHR), a subset of EHR information to which consumers will have access. Requirements for the PHR are incorporated in the HL7 trial standard for EHRs. At minimum, the PHR should be available to consumers as a life-long record and kept permanently.

Patty: What to retain and for how long will be an individual organizational decision as it is today in a paper-based environment. One of the most important considerations from a legal record perspective is that an organization has a discovery response plan that identifies the process in an electronic environment to respond to a legal request. Basically the procedure needs to include what constitutes a designated record set for release of information. And in the event that additional information is requested, that this information be provided based on EHRM policies.

Leslie: It’s getting harder to define the legal record, isn’t it Patty? Sounds like in some ways it’s up to the organization to define.

Patty: It is harder in that no one authority is defining the legal record. But what we do know is this: electronic original source documents take on many forms, which include digital diagnostic images, scanned (digitized) documents, magnetic tape, digital dictation, digital photographs, video files, wave forms such as electrocardiograms, transcribed reports and digital conversations such as e-mail. And of course individual components of an EHR such as clinical documentation systems, computerized physician order entry, etc.

Organizations need to determine which source documents they define as part of the legal record and which documents are considered secondary data or raw data. A designated record set should then be defined for release of information purposes with a discovery process in place to gather secondary data as requested.

Leslie: Leading the transition in EHRM is a great challenge. We will have a lot more to discuss in future columns as we hear more from our readers and colleagues about how they are addressing these compelling issues. In the mean time, I encourage our readers to read two key EHRM references located in the AHIMA body of knowledge:

• Kohn, D., “When the Writ Hits the Fan: The Importance of Managing Electronic Health Records as Business Documents,” Journal of AHIMA: September 2004 pp: 40-44.
• The Strategic Importance of Electronic Health Records Management—product of an AHIMA e-HIM™ practice standards workgroup.

Good luck to each of you as you guide your organizations through the implementation of EHRM best practices.

Leslie Ann Fox is chief executive officer and Patty Thierry Sheridan is president of Care Communications Inc., a national HIM consulting and staffing company headquartered in Chicago. They invite readers to send their thoughts and opinions on this column to lfox@care-communications.com or pthierry@care-communications.com .