Appendix A: HIM Practice Checklist Business Requirements HIM Practice Checklist Use Case Information Availability (A) 1. Maintain information in a manner that ensures timely, accurate, and efficient retrieval. A1. All documents can be accounted for and the record closed as complete within a specific time period post patient discharge in accordance with and Federal regulations, accreditation organizations (e.g. Joint Commission, Det Norske Veritas Healthcare - ISO 9000), or organizational policy A1.1. All documents can be accounted for within a specific time period post completion episode of care/encounter A1.2. Record is closed as complete within a specific time period post completion of the episode of care/encounter 2. Enable trust of requestor in information by ability to ensure the timeliness, accuracy (completeness and correctness), and efficiency of information availability. A1. All documents can be accounted for and the record closed as complete within a specific time period post patient discharge in accordance with and Federal regulations, accreditation organizations (e.g. Joint Commission, Det Norske Veritas Healthcare - ISO 9000), or organizational policy A1.1 and A1.2 (above) 3. Ability to identify, locate, and retrieve the information required to support organization’s ongoing activities via queries and access to data across various systems. A2.Single or multiple groups of documents within the electronic medical record can be viewed by or released to the requestor as allowed by Health Insurance Portability and Accountability Act (HIPAA) A2.1. Single and multiple (submission sets) documents within the electronic medical record can be viewed by or released to the requestor for treatment, payment, and healthcare operations use and disclosure. A2.2. Single and multiple (submission sets) groups of documents within the electronic medical record can be viewed by or released to the requestor for use and disclosure requiring a signed authorization. 4. Ability to address multiple demands having the right information available at the right time for the right requestor A2.Single or multiple groups of documents within the electronic medical record can be viewed by or released to the requestor as allowed HIPAA A2.1 and A2.2 5. Ability to search for information in continually expanding volumes of information and multiple systems A2.Single or multiple groups of documents within the electronic medical record can be viewed by or A2.1 and A2.2 (above)
including multiple electronic and manual systems. released to the requestor as allowed HIPAA 6. Ability to assemble information from disparate electronic systems, both internal and external to the actual or virtual location(s) of the organization. A2.Single or multiple groups of documents within the electronic medical record can be viewed by or released to the requestor as allowed by HIPAA A2.1 and A2.2 7. Ability to access information created with legacy hardware and software systems. In case of impending system obsolescence, information with organizational value should be migrated to currently supported hardware and/or converted into a format. A2.Single or multiple groups of documents within the electronic medical record can be viewed by or released to the requestor as allowed by A2.1 and A2.2 8. Ability to maintain metadata services across all participating systems assigning structural and descriptive characteristics to information including data provenance information, e.g., authors and dates of creation, modification, sending, receipt, access, etc. To be developed (TBD) TBD 9. Ability to manage both vendor relationships and employee turnover to maintain the workforce capabilities on the most current methods to access information. TBD TBD 10. To ensure levels of redundancy, failover, contingencies and risk management practices to minimize risks of non-availability of information due to a disaster, system malfunction, or data corruption. TBD TBD 11. A3. A log of all requests and accounting of disclosures is kept as an audit trail and can be referenced as needed. 12. A4. Full chart management functionality (i.e. Record Lifecycle Management) to verify the identification of location of the source of the release, completeness of the documents being released, and destination for the release or review
and approval by the compliance officer if not otherwise allowed by law. A written record is kept by the complaisance officer and available for audits. Information Integrity (I) Maintain information in a manner that ensures confidence in its authenticity, timeliness, accuracy, and completeness. A4. Full chart management functionality (i.e. Record Lifecycle Management) to verify the identification of location of the source of the release, completeness of the documents being released, and destination for the release or review are available in the release of information software. TBD Ability to maintain integrity of information to comply with safety, quality of care, and compliance with applicable voluntary, regulatory and legal requirements, A6. Accurate capture of patient data by electronic health record system. Reduction of medical errors that cause inaccurate recording of patients' allergies and medications, compromising quality of care and patient safety. Ability to maintain integrity of information in adherence to the organization’s policies and procedures. I1. Performance of a duplicate medical record number and account number validity checking process in place. Enterprise-wide process exists for notification of duplications. Process of merging paper and electronic records. Ability to provide appropriate workforce training on information management and governance to support integrity of information. I2. Proper training and support of system user is paramount to preventing system errors that can potentially contribute to suboptimal healthcare quality. Enable trust of requestor in the integrity of information by ability to ensure the authenticity, timeliness, accuracy, and completeness, admissibility of records for litigation purposes A1. All documents can be accounted for and the record closed as complete within a specific time period post patient discharge in accordance with State and Federal regulations, accreditation organizations (e.g. Joint Commission, Det Norske Veritas Healthcare - ISO 9000), or organizational policy. A1.1. All documents can be accounted for within a specific time period post completion episode of care/encounter A1.2. Record is closed as complete within a specific time period post completion of the episode of care/encounter Ability to ensure integrity of information through reliable system controls that support the organization’s ongoing activities across various systems.
Scan of ROI Request Release of information logs must be retained for 6 years. (HIPAA Privacy Rule) The following disclosures must be accounted for: Government mandated reporting Research Disclosures by business associates that are not for treatment, payment, and healthcare operations Though exceptions apply, disclosures typically included in response to an AOD request include: All disclosures of PHI that are not for treatment, payment, or delivery of healthcare operations Suspected domestic and child violence and abuse reporting Disclosures made for research unless authorized by the patient or legal representative Disclosures made to government agencies (excluding intelligence/national security) Disclosures to public health authorities Disclosures to the Food and Drug Administration Disclosures to employers Disclosures to health oversight agencies Vital statistics reporting Disclosures to law enforcement Disclosures regarding deceased persons Disclosures for research purposes Disclosures for specialized government functions Disclosures for workers' compensation purposes Appendix C: Glossary Term Definition Clinical Pathway A flow of activities and documentation derived from the clinical guidelines as related to a specific episode of care (Figure 5). Clinical pathway is a tool designed to coordinate multidisciplinary care planning for specific diagnoses and treatments. Clinical pathway – also as a clinical workflow document (specification or checklist) – is developed by physicians (medical informaticians) at the facility. It serves as a practice management protocol. This protocol defined information and data requirements (forms, documents) associated with the episode of care. The information and data requirements (forms, documents content) are also called case definitions, i.e., specific instructions on how to document specific activity within the function based on the clinical guidelines. The oversight of the correct recording of information according to the clinical pathway protocol and case definition is conducted by the facility’s Clinical Documentation Improvement (CDI) team of the HIM department. CDI team is also involved in developing templates (standardized formats) for forms and documents used in the clinical pathway to document the episode of care/encounter.
timeliness, accuracy, and completeness, admissibility of records for litigation purposes 6. Ability to ensure integrity of information through reliable system controls that support the organization’s ongoing activities across various systems. EHRS FM R2 ISO/HL710781 ISO IS 22600-1 2014 7. Ability to classifying and manage information received from disparate electronic systems, both internal and external to the actual or virtual location(s) of the organization. EHRS FM R2 ISO/HL710781 ISO/IEEE IS 2004 ISO/IEEE IS 11073-10103 2014 ISO/IEEE IS 2004 ISO/IEEE IS 11073-10404 2010 ISO/IEEE IS 11073-10407 2010 ISO/IEEE IS 11073-10408 2010 ISO IS 13606-3 2009 E1384-07 E2369-12 E2473 8. Ability to demonstrate oversight by senior management of adherence to approved policies and procedures necessary to maintain reliability of information. 9. Ability to ensure reliability of data and information based on the nature and type of healthcare organization processes and systems for creation and capture, processing, and other applicable stages of the information’s lifecycle. EHRS FM R2 ISO/HL710781 ISO/IEEE IS 11073-10101 2004 ISO/IEEE IS 11073-10103 2014 ISO/IEEE IS 11073-10201 2004 ISO/IEEE IS 11073-10404 2010 ISO/IEEE IS 11073-10407 2010 ISO/IEEE IS 11073-10408 2010 ISO/TS TS 21547 2010 10. Ability to implement ongoing quality control measures include field-specific data edits built into systems/applications; monitoring and correction of vendor identity errors and patient identity errors; monitoring and correction of documentation completeness and data accuracy; and ongoing data quality controls. E2117- 06 11. Ability to prove reliability and integrity of the information through the employment of audit trails that are acceptable and verifiable. EHRS FM R2 ISO/HL710781 ISO IS 22600-1 2014 E2147-01 Information Protection 1. Ability to ensure appropriate levels of protection from breach, corruption and loss are provided for information that is private, confidential, secret, classified, EHRS FM R2 ISO/HL710781 ISO IS 27799 2008