Electronic Records Policy
Title: CONVERSION TO ELECTRONIC RECORDS
Information Systems, Effective Date: November 1998
POLICY
To assist in meeting our mission to provide high-quality home health products and services in a cost-effective manner, Partners Home Care will convert to an Electronic Medical Record System in November 1998. The following procedures will outline the conversion process as well as refer to the necessary policies, procedures, and agreements that are modified or added to meet the needs of an electronic medical record system. The procedure will also outline the ongoing process changes to meet the recommended government standards for electronic medical record keeping.
PROCEDURE
1. The agency will name a Health Information Security Officer (a.k.a. System Administrator), as well as a backup. When possible, the Health Information Security Officer will be the Director of Information Systems, and the backup will be another Information Systems associate familiar with the Clinical Link/Total Home Care systems. In the absence of the Health Information Security Officer, Security Officer access will be given to the back-up person.
2. The Health Information Security Officer’s role is to ensure the integrity, reliability, accuracy, and security of information and data in the Clinical Link/Total Home Care system. This is accomplished by:
a. Limiting system administration duties to the Health Information Security Officer.
b. Limiting knowledge of the root password to Health Information Security Officer and backup.
c. Changing root password periodically, after access by Delta for maintenance operations or after any critical event:
(1) Suspected breach of security
(2) Employee with root password knowledge terminates employment
d. Establishing access security controls by job descriptions and assure they are implemented to reasonably protect information.
e. Authorize and implement changes in access only by written request. The request includes information regard- ing who is generating the request, the access to be increased or denied, the reason, the effective date and the termination date of modified access if there is one, approval or denial notation by the security officer. These will be kept on file for reference.
f. Implement appropriate security measures over software and hardware to reasonably ensure the protection and integrity of information.
g. Periodically reviewing and/or revising the Information Systems policies and procedures to ensure adequate data protection.
h. Identify, establish protocols, and obtain licensure for any software deemed necessary for agency functioning that will not compromise data integrity by establishment of change requests and testing procedures for all changes in hardware, software network.
3. A new COMPUTER AND INFORMATION USAGE AGREE- MENT will be explained to all current associates having any access to the Clinical Link/Total Home Care system, their understanding verified, and signature obtained.
a. 100% compliance will be accomplished prior to the implementation of electronic medical records.
b. This agreement will become part of the orientation of new employees after that time. Access to data systems will not be allowed until this agreement has been reviewed and signed by the new employee having any access to the Clinical Link/Total Home Care system.
c. Any employee who, by virtue of change in job description, gains access to the Clinical Link/Total Home Care system, will be trained regarding this agreement and signature obtained.
d. This agreement will then be reviewed and signed annually by all associates having access to the Clinical Link/Total Home Care systems.
4. On the date chosen for implementation of the electronic medi- cal record system, all active paper-based charts will have a notation made in them that as of that date, further documenta- tion is contained only in the electronic medical record, with the exception of the following:
a. Documentation requiring the patient’s signature (i.e. Bill of Rights, Consent for Treatment, other written consents that may be needed).
b. Documentation requiring the physician’s and/or nurse’s signature (i.e. 485s, verbal orders).
c. Documentation from physical therapists, occupational therapists, and speech therapists whose services are contracted through vendor services (i.e. evaluations, progress notes, discharge summaries).
d. Documentation from third-party payers.
e. Documentation received from outside sources such as transfer forms, lab reports.
5. All paper documentation from any admission occurring on and after the electronic medical record implementation date will be kept in a modified chart system such as those currently used for discharged charts.
6. If there is a request for copies of the medical record as per agency policy, the Health Information Specialist or other designated person will print the requested documentation. At that point, the printed documentation will need to be signed by the person who entered the data, and any reviewer if so indi- cated on the documentation, and described in the Computer and Information Usage Agreement.
7. All policies addressing documentation and medical records will be reviewed, and when necessary, a second policy will be drafted reflecting the procedure in an electronic medical record system. These policies can be modified to include, but may not be limited to:
a. Confidentiality
b. Personnel Record Entry/Review
c. Information Systems: Content Medical Record
d. Information Systems: Clinical Records Confidentiality
e. Information Systems: Individual Record
f. Information Systems: Record Format
g. Information Systems: Accessibility and Storage
h. Information Systems: Authorized Personnel Record Entry/Review
i. Information Systems: Release of Information: Request for Correction/Amendment to Health Information
j. Information Systems: Release of Information: Revocation of Authorization for Disclosure of Health Information
k. Information Systems: Release of Records
l. Review of Discharge Records
m. Billing audit
n. Any and all Clinical Policies and Procedures related to Documentation in the Medical Record.
8. On an ongoing basis, the Quality Improvement/Information Systems departments will move forward on addressing the recommendations from the federal government on further design of the electronic medical record as contained in the document Draft of Electronic Signaturing and Security Policy of Patient Electronic Health Record of Sept. 4, 1998. This will include new measures needed, as well as integration of current policies and procedures so there is one cohesive document on Partners Home Care electronic medical records.
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