new electronic health records system H e a l t h M e d i c a l

new electronic health records system H e a l t h M e d i c a l


Capstone Video: The Hallway Incident

[ Music ]

>> Oh, no. Oh, my God. Sir? Sir, can you hear me? Can you hear me, sir? Oh, my God.

>> Is he okay? Did you see what happened?

>> No, he slipped. He won’t open his eyes.

>> Are you a nurse?

>> No, I’m a coder.

>> Should we get one?

>> Hey. Hey you. Are you a doctor?

>> Can you believe him? Okay.

>> Sir?

>> Call the ER. Tell them we have an emergency in the lobby.

>> Okay. I’ll go do that. Is he bleeding?

>> Go. Are you okay, sir?

>> Oh, my head.

>> Oh, no. He’s bleeding. Okay. Tell them that he’s bleeding from the head. Okay. Sir, just — the doctor’s on the way. Okay. Just remain calm. Lie still. Okay. You’re going to be fine. Just stay down and lie still.

>> Hospitals are healthcare facilities. Should someone fall or become injured anywhere on hospital grounds, all staff, not just doctors and nurses, have a responsibility to respond to the injured party whether it’s a visitor, a patient, or even another hospital employee. Any healthcare facility should have an established system of communication so that help can be summoned in just such an emergency. Typically the PA system is used for this. In most cases, different codes are utilized to alert facility personnel to the nature of the emergency such as a fire, a fall, a security breach, and so on. This allows the right people to respond appropriately and immediately. There should also be an administrative policy maintained on both the codes and for incident reporting. The HI department, like any other department, needs to maintain the policies applicable to them, usually within a policy and procedure manual. Now this particular incident didn’t seem life-threatening once the visitor woke up and became alert. Even so, all the precautions must take place. Your facility needs a policy for completing an incident or injury report immediately after it occurs. And any employee or employees who witnessed the incident must fill out an incident report. If anyone on the hospital staff witnesses an incident and fails to respond appropriately, disciplinary measures should be taken. These measures too should be outlined in the hospital’s incident reporting policy.


Why was the health information staff (coder) responsible for assisting the visitor who had fallen?

Where should a policy/plan be maintained as a resource tool for HIM staff to refer to?

If the staff failed to respond to the visitor’s fall, how could their jobs be impacted? How could the hospital be impacted?


Capstone Video: EHR without HIM

[ Music ]

>> I just wanted to talk to you about something that I heard.

>> Shoot.

>> Are we implementing a new electronic health records system?

>> Yep, welcome to the new millennium I guess.

>> Yeah, well that’s the point; I’m just surprised that I was not at all involved in the process.

>> Well, we had no way of knowing that you’d want to be, I mean, it’s all computer-based. We just figured it was something for the guys in information systems.

>> And you really didn’t think that information management should be involved? I find that very surprising.

>> We didn’t intentionally exclude anyone; is there a problem?

>> I don’t know. I don’t know let me just ask what are the auditing and retrieval capabilities?

>> And listen, I don’t have the specs in front of me right now. I’ll get you the specs.

>> Will the reports keep us in compliance with HIPAA and CMS? Will it prompt for counter suit features? What kind of retention capabilities will it have?

>> These are all good questions.

>> Thank you.

>> I’ll tell you what, why don’t we just have you come to the next EHR committee meeting?

>> Thank you.

>> And that way you can have all of your questions answered there.

[ Silence ]

Okay let’s get started. Before we get to the agenda, everyone knows Barbara Gonzalez? I’ve invited her here today because she felt strongly that HIM should be a part of EHR. We spoke last week and she raised some questions that I thought would be valuable for us to cover, so Barbara.

>> Thank you. I’ve actually worked closely with the EHR systems at the hospitals I’ve worked at previously, so I was anxious to look at the specs and see what was called for in the RFP that was sent out to the vendor, and actually I was very surprised. The EHR system called for doesn’t really meet the standard definition of EHR. We should expect our EHR to meet HIM requirements for both accreditation and state licensure; neither of which are called for in this RFP. The system described here will be deficient in terms of documenting and analyzing retention, and doesn’t come close to offering the additional security requirements that HIPAA requires. There’s no audit trail for amendments, no accounting of disclosures, and it doesn’t generate reports for chart deficiencies, workflow or anything else that we might want. To be honest with you what we’re getting with here sounds good on paper, but once you look at the details it doesn’t begin to give us what we need to stay compliant. To put it bluntly I think you’re getting a white elephant here. I appreciate that this is not what you want to hear.

>> Well, for me much of the benefit of the EHR in the first place is helping us to stay compliant. Bill, can we cancel the RFP so that we can take another look at it?

>> Sure.

>> Okay.

>> No problem.

>> Maybe we should work with Barbara to rewrite the RFP so that we address all of the HIM issues.

>> Which is maybe what we should have done in the first place.

>> Okay Bill, cancel the RFP.

>> Cancelled.

>> Barbara, I owe you an apology for not bringing you in on this from the beginning.

>> Well, I’m just glad it’s not too late for us to still get what we need.

>> Me too.

>> Here here.

>> Okay, it sounds good to me.


Why should the EHR team be interdisciplinary?

Why would or should HIM professionals be involved in the implementation of an EHR system?

Was the HIM director acting appropriately in going to the CIO and asking to be involved?

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