Growth of networks means new standards
Brush up on the systemwide philosophy
The ever-widening continuum of care that focuses on the outpatient environment will force health information managers to pay heed to new directions taken by the Joint Commission on Accreditation of Healthcare Organizations.
The Joint Commission has created new categories of accreditation, including a health care network accreditation. It has also changed its approach to surveys. Instead of focusing on individual departments, it now evaluates such specific functions as information management, throughout the organization.
The Joint Commission tailors its surveys to reflect the services offered by each organization. A single accreditation is awarded to a hospital and the physician practices it owns or operates. Each service is evaluated according to the relevant set of accreditation standards, such as hospital or ambulatory care standards, notes Caroline Christensen, a research associate in the Joint Commission’s department of standards.
Surveyors evaluate the organization based on how well it integrates and coordinates each function across all facilities. The information management function, for example, would be looked at across the continuum of care within the organization.
"The basic functions like information management are the same for each setting," Christensen says. "You have to be concerned about confidentiality and the availability and timeliness of information in all settings. You may carry the functions out differently, but they have to be consistent across the organization."
Specific issues that must be resolved include:
• Should outpatient records be kept in a central location or at the clinics where they are generated?
• Does the entire medical record need to be transferred or can it can be separated into different components?
• Which parts of the record are essential for patient care, and which aren’t?
• How can duplication of paperwork be avoided?
The answer to the first question may boil down to a struggle over control, convenience, and efficiency. Ultimately, however, it will be the hospital health information manager’s responsibility to comply with standard IM 7.9 of the Oakbrook Terrace, IL-based Joint Commission. Standard IM 7.9 states:
"The hospital can quickly assemble all components of a patient’s record, regardless of their location in the hospital, when the patient is admitted or is seen for ambulatory or emergency care."
How to do it
The Joint Commission’s 1997 Comprehensive Accreditation Manual for Hospitals offers three examples of how this can be done:
• Combine records of care from different areas by:
using the unit record;
inserting ambulatory care and emergency care records in the inpatient record at the time of inpatient admission;
inserting significant material such as the discharge resume, operative notes, and pathology reports from the inpatient record into the ambulatory care and emergency care records.
• Implement a computer-based patient record.
• Develop a protocol for what is requested by discipline and physician and provide it to the practitioner in a timely manner.
Keep in mind that while many of the information management standards in the hospital and ambulatory care manuals are similar, there are also some differences especially in the intent statements.
In addition, the standards on operative reports in the ambulatory care manual are more detailed than in the hospital manual.
"Health information managers need to read both sets of standards carefully, to make sure they are covering everything," Christensen advises.
Bear in mind that some hospitals surveyed by the Joint Commission in 1996 were advised to add ambulatory records to quarterly medical review processes and to include representatives of ambulatory care services on their medical records committees.
Another problem of decentralized health care is maintaining medication lists and problem lists for individual ambulatory care patients. This is required by Joint Commission standard IM 7.4.
"We have to have a summary list by the third visit and maintain it thereafter," says Jeanne Kistner, RRA, director of health information services at Oregon Health Sciences University (OHSU) in Portland. "This gets difficult when the patient moves in and out of different ambulatory care settings. And if a patient is prescribed medication by both a primary care and specialist physician, it all needs to be included on the patient’s medication list," Kistner points out.
OHSU is moving toward developing computerized problem and medication lists. Obviously, the more on-line a hospital and its outpatient clinics are, the easier it is to keep records up to date in a central data repository. At OHSU, the notes that a physician dictates go into a clinical data repository that can be accessed at any time. The repository stores dictation, lab and radiology reports, diagnoses, and procedures. It is not comprehensive, however. So OHSU is developing a strategic plan for information management to accommodate its push into ambulatory care settings, Kistner says.
She also heads a project to develop a lifetime clinical record that will enable OHSU to follow patients from clinic to hospital, as well as to other care settings to which the hospital may discharge or transfer them.
"One of the most significant challenges we are facing is whether there should be a single outpatient record or a combined inpatient/outpatient record," says Kistner. "We traditionally have a comprehensive unit record that combines inpatient and outpatient. But what we are seeing as we open satellite clinics is that they want the information there and set up their own patient record. The question is, how does that information get back into the main hospital record? Do we duplicate more and more paper? Do we even need a copy, or should we just access their records when we need them?"
[Editor’s note: The Joint Commission has released the latest version of the 1997 Comprehensive Accreditation Manual for Hospitals: The Official Handbook (order code CAMH-97, $325). The major change in the information management section is the elimination of the physician authentication requirement in many cases. This version of the manual is expected to be used for several years. It provides updates that hospitals can purchase on a quarterly basis through a subscription option ($225).
A software version, The Automated CAMH, (order code AH-97, $595) is also available. Quarterly updates will cost $395. In addition the Joint Commission is offering a new publication, Hospital Accreditation Standards (order code HAS-97, $85) as an easy reference guide.
All versions can be ordered through the Joint Commission’s customer service center. Telephone: (630) 916-5800.]
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