# Presentation: 694251

## 235 VistA Imaging - Document  Imaging Policy and Procedure

- Pamela Heller, RHIA, CCS-P
- Garrett Kirin
- Cliff Sorensen

**Notes:**
Hello.  This session is VistA Imaging – Document Imaging Policy and Procedure, session number 235.  My name is Pam Heller and I work at VA Central Office in HIM.  Garrett Kirin from VistA Imaging Development, Silver Springs Office of Information Field Office will be co-presenting this session. Cliff Sorensen, who is a trainer with VistA Imaging may assist with questions at the end of the session.

As a reminder, please put your questions on an index card.  Questions will be read and answered at the end of the session.

## Table of Contents

- Objectives
- VHA Handbook 1907.01
- Scanning Requirements
- Websites
- _[Scanning FAQ](slide12.xml)_
- _[New Index Term Requests](slide24.xml)_
- _[Patch Releases](slide20.xml)_
- Q&A _[  ](slide18.xml)_

## Objectives

- Session will cover HIMS requirements
- Medical Legal requirements
- Destruction of paper documents
- Indexing images & documents

**Notes:**
This session will discuss the Policies and Procedures related to document capture from a HIM perspective to include information on VHA medical legal requirements of document retention, destruction of paper documents, and labeling of captured images and documents. The session will also discuss the process for new index terms and where to locate imaging references on the VA intranet, such as the HIM Scanning page, VistA Imaging websites, VHA Handbook 1907.01 “Health Information Management and Health Records.”

## Objectives

- Where to find references
- HIM Website
- _[http://](http://vaww.vhaco.va.gov/him/Scanning.asp)__[vaww.vhaco.va.gov/him/Scanning.asp](http://vaww.vhaco.va.gov/him/Scanning.asp)_
- VistA Imaging Websites
- _[http://](http://vaww.vistau.med.va.gov/vistau/vistaimaging/)__[vaww.vistau.med.va.gov/vistau/vistaimaging](http://vaww.vistau.med.va.gov/vistau/vistaimaging/)__[/](http://vaww.vistau.med.va.gov/vistau/vistaimaging/)_
- http://vaww.va.gov/imaging/IMGdocumentimaging.htm
- http://indextracker.imaging.med.va.gov:8080/indextracker
- VHA Handbook 1907.01
- Scanning FAQ

## VHA Handbook 1907.01

- Dated August 25, 2006
- Scanned wet-signed documents linked to TIU documents
- Documents that cannot be created in or interfaced with CPRS will be scanned
- Document imaging process

**Notes:**
This slide covers the current requirements in 1907.01. 

Scanned, wet-signed documents may be linked to TIU documents and displayed with the TIU document. Scanned documents do not require an electronic signature, but are marked administratively completed. 

(2) Only those documents that cannot be created in or interfaced with CPRS will be scanned. Development of document scanning policies is a shared responsibility among HIMS and other appropriate services. 

(3)  Document scanning, or document imaging, is a process by which a paper document is converted to an electronic file.  

## VHA Handbook 1907.01

- Local policy needs to address:
- Quality control processes
- Correction process of erroneously scanned documents
- Staffing issues
- Handling of external source documents
- Annotation to identify image has been scanned

**Notes:**
Local policy needs to address:
	(a)  Quality control processes for:  
	   1.  Image quality and alternative means of capturing the data when the quality of the source document cannot meet image quality controls,
	   2.  Integrity of data capture,
	   3.  Accurate linking of scanned items or documents to correct record, and
	   4.  Accurate indexing of the document.
(b)  Correction process of erroneously scanned documents. 
	(c)  Staffing issues such as who is authorized to create administrative progress notes for scanning, who is given permissions to scan documents after meeting competencies, and where scanning will take place (centralized versus decentralized scanning). 
	(d)  The handling of external source documents (see par. 6).
	(e)  How a scanned image will be annotated to identify that it has been scanned; for example, using a stamp on the scanned document.

## VHA Handbook 1907.01

- External Source Documents
- _Authenticated_ documents
- Practitioner indicate documents to be retained
- Summary progress note
- Part of health record once scanned/filed
- Request to amend to original source

**Notes:**
External Source Documents.  Only those external source documents that are authenticated may be maintained as part of the patient’s VHA permanent health record at the practitioner’s written request.  Practitioners must indicate which documents need to be retained and limit this to pertinent, present, and/or continued care.  A summary progress note written by an appropriate clinician after a review of the external source documents may be used in lieu of filing and/or scanning any external source documents.

	(a)  Any documents or information filed, maintained, or scanned into a patient’s health record, including external source documents, are deemed to be part of the patient’s VA health records.  These records are subject to all applicable Federal regulations concerning maintenance and disclosure including the Privacy Act of 1974 (5 U.S.C. 552a) and VA confidentiality statutes.  Once a document is filed, absent Federal law or regulation to the contrary, it becomes a VA record subject to protection and release under Federal law.  

	(b)  A request to amend an external source document must be referred back to the original source.

## Scanning Requirements

- 75 year retention requirement
- Minimum scanning resolution
- 300x300 dot per inch
- Destruction of source documents
- Source document is indexed
- Imaged as an exact replica of the original document
- Quality control processes are in place
- Assurance that the imaged document is stored, accessible and retained according to the 75 year retention requirement

**Notes:**
The National Archives and Records Administration (NARA) disposition authority for electronic health records allows VA to destroy source documents after scanning, but only if record retention and retrieval requirements can be met, and quality control processes are in place.  In accordance with the NARA disposition authority, imaged records must be retained to satisfy the "75-year after the last episode of care" retention requirement.  Original source documents may be destroyed after scanning as long as record retention and quality control processes are met.  Source documents may also be retained if there is a compelling business reason to do so.

A question was added to the FAQ concerning whether it is VA’s policy and plan to migrate existing electronic data in VistA Imaging to whatever standard is necessary to view those data to remain in compliance with NARA’s 75 year retention requirement? 

Yes.  Sites should ensure that there is a daily backup of the entire system to include both CPRS and VistA Imaging.  Back-ups should be performed in accordance with VistA and VistA Imaging implementation guidelines. 

## Scanning Requirements

- Is Printing & Filing Necessary
- Electronic and digitized records can be efficiently identified for authorized uses
- Images are retrievable and legible
- Integrity of digitized records is maintained

## Websites

- HIM Document Scanning Page
- http://vaww.vhaco.va.gov/him/Scanning.asp
- Scanning FAQ
- VHA Handbook 1907.01
- Position descriptions
- Standards and competencies
- Policies and procedures
- Links:  VistA Imaging and VI Term Tracker

## HIM Document Scanning

## Scanning FAQ

- Distributed July 2007
- Responses to FAQ with references
- Categorized
- Collaboration between VACO HIM Office, VACO VistA Imaging Office, National Center for Ethics in Health Care, VACO Privacy Office, Health Eligibility Center, VACO Pharmacy Benefits Management, the National Archives and Records Administration, and VHA Radiology Program

**Notes:**
An updated scanning FAQ was distributed to the field in July 2007.  
References were given with the response, such as VHA Handbooks 1605.1 and 1907.01.  

The questions and responses were categorized in alphabetical order to assist in finding a question easily.  Several of the new questions will be discussed.

As in the past, many of the responses were collaborated with various program offices, such as Collaboration between VACO HIM Office, VACO VistA Imaging Office, National Center for Ethics in Health Care, VACO Privacy Office, Health Eligibility Center, VACO Pharmacy Benefits Management, the National Archives and Records Administration, and VHA Radiology Program.

The scanning FAQ is on the HIM Website on the document scanning page.  

## Scanning FAQ

- Administrative Documents
- Link to Patient Only
- Viewable in VistA Imaging
- Administrative correspondence
- Copyrighted Documents
- Permission to use copyrighted documents

**Notes:**
Administrative correspondence should be scanned and linked to the patient only in VistA Imaging.  ROI cover letters and authorizations should be scanned and linked to the patient only.

The facility must have permission to use copyrighted documents.  If the facility purchased forms for patient treatment, these could be scanned.  Sometimes when copyrighted forms or a book is purchased, it will indicate that x number of copies can be reproduced.  There are also forms that are part of the public domain and can be used in anyway so these could be scanned as well.
You can use the Adam diagrams in iMed to diagram.  However, you cannot copy the Adams diagrams in iMed and use the diagram as a diagram in the VI Online Diagram Annotation Tool.  There isn’t a licensing agreement to use Adams diagrams with anything other than iMed.  The diagrams in MediaNet can be downloaded and used with the VI Online Diagram Annotation Tool.  VHA VI Index Term Review Board has been working with VA illustrustrators to develop additional diagrams in MediaNet that are needed.  If sites have diagrams that they would be willing to share, please send. 

## Scanning FAQ

- Corrections
- Consent attached to wrong patient
- Image scanned on wrong patient
- Scanned document with wrong SSN
- Destruction
- Shredding source documents
- Daily backup
- Non-VA prescriptions

**Notes:**
SSN - Print the image, make a pen/ink correction of the social security number, initial and date the correction, and scan the corrected version into the correct patient’s record.  The incorrect scanned document would be deleted with the corrected version scanned in its place.

Tracings not in CPRS found in Cardiology.  Per RCS 10-1, the tracings cannot be destroyed and the notation states “Disposal requirement suspended pending appraisal of tracings in electronic format”.   A recommended best practice from Puget Sound for the tracings as well as EKG tracings is for Cardiology to box them in NARA shipping boxes by year/month and send the boxes to HIM. Once every year or two, HIM will ship the boxes to Neosho inventoried only by year and month of the test.  The facility does not list every EKG in the box but the following information: EKG’s box 1 Jan 06 to March 06, Box 2 April 06 to June 06, etc. When Nara finally makes a decision regarding the destruction date for these cardiology tests, then Neosho can be contacted to destroy the boxes on a certain date.

## Scanning FAQ

- Fee Basis
- Scanning fee basis reports
- Filing/Printing
- Tracings
- Unable to scan good copy of document
- Paper records when file room is closed
- Identification on Digital Pictures
- Close-up digital pictures
- Laboratory slide

**Notes:**
Process when you cannot scan something that should be scanned because it is technically impossible to get a good copy and place it in the record. Confirm the minimum resolution is 300x300 dot per inch (dpi).  Sometimes, changing the setting to a higher resolution will help to scan adequately.  If the document is still unreadable even with copying and changing scanning settings, file the document in the health record.  A best practice would be to scan a page telling the user that the document is filed in the health record. 

Paper records received when file room is closed.  Scan.  If too large, keep on a shelf then retire to NARA.

To identify patient photographs, take a picture with the patient identification (name, last four numbers of the SSN, DOB), such as an index card with the information to be used as the first image in the study.  Then take the close up picture(s).  Finally take another identification picture at the end.  The identification pictures will be the first and last picture in the series with the non-identified close-up pictures in the middle. It may be beneficial to take a wide angle picture(s) before the close-up pictures when possible.

The preferred method is to use the DICOM modality work list interface which automatically provides the patient identifying information to the instrument.  When this is not feasible, use the clinical capture application to select the patient for each individual image study.  

## Scanning FAQ

- Index Terms/Fields
- Requesting new term
- List of scan documents
- Capture of index fields
- Linking Scanned Documents
- Patch 59
- Linking to visit date
- Procedure/Event Inpatient Stay

**Notes:**
In patch 8 of VistA Imaging, a list of VI index terms was distributed for indexing an image.  New requests can be made from the index term tracker website for approval/disapproval by the VHA VI Index Term Review Board.  Approved new index term requests are automatically sent via VA mailman to all the sites.

All fields should be filled in, but in some cases you may need to leave the Specialty or the Procedure/Event fields blank if there are no index terms which accurately describe the Image being captured.  Please consult your Imaging Coordinator and HIM staff regarding site specific guidelines for filling in the Optional Index fields.  Patch 61 released June 28, 2006  provides the utility that will automatically update VistA files including Image Index Term files by processing a VA MailMan message containing new values that have been approved by the VistA Imaging Index Term Review Board. This will assure that Index Term values are consistent across the VA. VI Capture software allows the sites to create specific Configuration Buttons that can contain values for the Index Fields.  This feature makes it easier for the scanning staff to process scanned documents in an accurate and consistent manner.

## Scanning FAQ

- Means Tests
- Do not delete scanned Means Tests
- Scan entire application
- Destruction of Means Test with wet signature
- Outside Records/Images
- External source documents
- Importing outside diagnostic images from CD to VI
- Date when scanning

**Notes:**
Practice brief #6 on the HIM website provides guidance of importing patient’s outside diagnostic images from CD into VistA Imaging.

## Scanning FAQ

- Privacy/Release of Information
- Amendment Denials
- Consent for pictures
- Certification of documents
- Remote Image View
- Report of Contact
- May be scanned

**Notes:**
Some staff still hand write report of contact (ROC) forms and some staff use the electronic form that is under the progress note tab of CPRS.  Since very few charts are pulled should these forms be routinely scanned?  Some staff says that the ROC form should not be in the medical record but in the administrative section of the chart.  If the ROC is filed, no one will see the form unless the chart is pulled which is rare.  Report of contact forms have a variety of uses as some include documentation that could go in the Electronic Health Record.  Therefore, when appropriate for the EHR, they may be scanned with the appropriate title to signify that it is an administrative document. 

## Scanning FAQ

- Retention
- 75 year retention
- 300x300 dot per inch
- Photos
- VistA Imaging Reports
- Patch 77
- What to Scan and What Not to Scan
- Social Security Number

**Notes:**
Garrett will discuss patch 77 when reviewing patch releases.

Documents containing the veteran’s full social security number on the document may be scanned into VistA Imaging.  However, the preferred method is to indicate the last four numbers of the social security number.

## Index Terms

- Purpose of Index Terms
- Website for requesting term
- 	http://indextracker.imaging.med.va.gov:8080/indextracker/
- User help guide
- How to request a new term
- Review process

**Notes:**
An index term tracker was developed to allow users at VistA Imaging sites to request new index terms for describing and categorizing images and scanned documents.  Sites are no longer allowed to enter index terms locally as the purpose of the tracker is to maintain a universal set of terms across the VA.  The tracker provides a method of tracking all requests with the status of the request. With the installation of Patch 61, a new distribution method was implemented so any approved Index Term requests are distributed to the sites in a matter of days through automatic updates to the VistA Imaging Index Files.   Updates to the Index Files are distributed to Patch 61 sites in a MailMan message.  The Utilities introduced in Patch 61 will enable the site to process the MailMan message and during this process the Index Term files are updated. 

A user help guide with instructions to enter a request is available on the website by selecting “User Help”.  Additionally, please note the following when using the website:
Search the index to ensure that the request has not previously been entered.   

The VI Index Term Review Board meets the 1st and 3rd Monday of the month.

## Index Term Request

- Click to edit Master text styles
- Second level
- Third level
- Fourth level
- Fifth level

**Notes:**
This is the page that will be displayed when you enter the tracker. The user help guide with instructions to enter a request is available on the website by selecting “User Help”.  

Search the index to ensure that the request has not previously been entered.  There are two ways to search.
To see if a request has already been entered, click on “Search for Index Request” and all terms that have been requested in the tracker will populate.  We ask that you always check to make sure the term has not already been requested.
The index term can be searched by the ID number that was assigned for a new request.  This can be utilized when checking the status of your request.

## Index Term Request

- Click to edit Master text styles
- Second level
- Third level
- Fourth level
- Fifth level

**Notes:**
This is what the screen displays when you enter a new request.
Some pointers when entering a request.  Non-VA should not be submitted in the name of the index term (Type, Specialty/Subspecialty, and Procedure/Event).  Instead, the origin “Non-VA” should be utilized with the appropriate term as a search can be performed on origin.  All terms can be used to classify Non-VA documents as well as VA documents.
Origin – What is the origin of the document, where did it come from VA, DOD, non-VA
Or Fee Basis
Class – Documents can be classified as clinical, administrative or both.
Type – Is a general definition, such as consent, medical document.
Specialty – Is a classification area, such as Medicine, Surgery.  It may or may agree with local facility specialties.  The DSS ROI package had to be mapped to national areas.  
Procedure/event – Is any test or treatment that a veteran receives either at the VA or non-VA site.

Under Term Details, explain in detail why the current available index terms will not suffice and the new term is needed.  If more information is needed, the requestor will be contacted via an email message.  

The checkbox at the bottom is automatically marked.  This will ensure that the requestor receives an email message when the request is approved, disapproved or additional information is needed to evaluate the request.    If a request is disapproved, will recommend an indexing scheme for that type of image as we are trying to have national standardization.  There has been discussion about mapping national approved TIU titles to document image index terms, specialties, procedure, event. For example, TIU consent form mapped to index term consent.

## Index Term Process

## Recent Patch Releases

- Patch 45 - Remote Image Views
- Released September 26, 2005
- View scanned images from other facilities
- View digital X-rays from other facilities
- Future related patch
- Patch 83 VA-DOD Image Exchange
- Summer 2008
- View DOD Images from VA
- View VA Images from DOD

**Notes:**
A New service request was entered so when the note title “Advance Directive” is changed to “Rescinded Advance Directive” a watermark will be automatically “burned” into the corresponding advance directive image to clearly indicate that the document has been rescinded. 

## Recent Patch Releases

- Patch 61 - Index Terms Update
- Released June 28, 2006
- Utility to automatically update VistA files including Image Index Term files
- Processed via VA MailMan message
- Terms approved by the VistA Imaging Index Term Review Board

## Recent Patch Releases

- Patch 77 - Image Activity Reports
- Released April 5, 2007
- Provides capability to generate reports from VistA Imaging
- Reports
- Document Count
- Image Type Count by User
- Means Test
- Package Index Contains 'Note'

**Notes:**
The four reports to obtain statistics from the IMAGE file.

Document Count:  Report of the Image file with images having an Image Type of 'DOCUMENT'.  A 'From' and 'To' Acquisition Site and 'From' and 'To' Date/time Image Saved will be asked.  Output includes:  Date/Time Image Saved, Object Type (DOCUMENT), Type Index, and Image Saved By. There will be a total of the count of images that meet the sort criteria.
Image Type Count by User:  Report of the Image file of Image Types for a 'From' and 'To' Acquisition Site' and a 'From' and 'To' Date/Time Image Saved date range.  The report will give totals for each Object Type, for each user, within date range.  A grand total of images within the  date range is given at the end of the report.
Means Test: Report sorted by 'From' and 'To' Acquisition  Site and 'From' and 'To' Date/Time Image Saved date range, and Type Index = MEANS TEST.  Report detail will include: Patient Name, SSN, Descriptive Category,  Date/Time Image Saved, and Export Location.
Package Index Contains 'Note': Report sorted by 'From' and 'To' Acquisition Site and 'From' and 'To' Date/Time Image Saved date range, Short Description, and Package index containing NOTE'.  Report detail will include: Patient Name, SSN, Short Description, Date/Time Image Saved, and Image Saved by.  Sub-counts and counts are given per Scanned By, with Short Description, within Patient.

## Recent Patch Releases

- Patch 59 – TIU <-> Imaging Enhancements
- Targeted for release August 2007
- Link Image to New Note, Addendum, Existing Note
- Administrative Closure
- Select date of document
- Date/Time of Image <-> Note Association

**Notes:**
Date/Time of Image <-> Note Association (was it before or after signature)

## Upcoming Patch Releases

- 62 – Imaging Release of Information (ROI)
- Print All/Selected documents and images
- Copy (Burn) Images to CD
- Create PDF from Images for export
- 93 – Imaging Display
- Usability enhancements - Image groups
- Filter enhancements
- 94 – Imaging Capture
- Multiple page color documents

## Future Patches

- Image View Status : Sensitive images
- Watermarking of Rescinded Advance directives
- Placeholder for Deleted Image
- No more scanning placeholder
- Image Edit functions
- Images scanned/attached to wrong report
- Images scanned/attached to wrong patient
- Image index Edit
- Modify index fields

## Questions

- Questions?