Health Information Management for the 21 st Century – It’s Not Just Medical Records Anymore

Patricia Griffin, RHIA Director, Health Information Services/Privacy Officer Catawba Valley Medical Center Hickory, North Carolina

Graduated in 1984 with a Bachelor of Science in Medical Record Administration Sat for national certification and became an RRA (Registered Records Administrator) credentialed through AMRA (American Medical Record Association) 2 years as an Assistant Director in Chicago 18 years as a Director/System Director at Valdese and Grace part of the Carolinas Healthcare System Last 6 years at Catawba Valley Medical Center as Director of Health Information Services (formerly known as Medical Records) and I am also the Privacy Officer

Catawba Valley Medical Center 248 beds All major services – no open heart, no transplant 1,000 admissions a month/12,000 a year Over 50,000 Emergency Department visits per year 7,500+ Same Day Surgeries 8 Medical Office practices with over 5,000 visits a month 16,000+ outpatient encounters a month 1300 FTEs and over 250 active members of the medical staff

Health Information Services has 47 staff members 23 work on site on the ChartMaxx Team, release of information, coding, statistics, and management 24 work at home as coders, transcriptionists, and Cancer Registrars

What is a medical record in the year 2010? a medicolegal document that serves as a repository for a patient’s medical history and the care given - otherwise known as a legal health record a document to provide continuity of care between care givers or care entities a planning tool for a patient’s next level of care may also be used in research and training it can be a paper only document or a hybrid of paper and electronically generated documents the department that keeps the records does not need to be located in the hospital – freeing up valuable real estate

The life cycle of a medical record… Patient is seen either as inpatient or outpatient The hospital information system (Meditech) sends a message to our electronic record storage system (ChartMaxx) Many pieces of information – labs, x-rays, transcribed reports, nursing notes, ancillary care notes, EKGs, OR and ED records, plus more are interfaced directly into ChartMaxx Most of the information is also printed for the patient record on the floor or in the outpatient area for the hands on caregivers

Looks something like this

The life cycle of a medical record… Physician orders, progress notes, anesthesia records, medication records, and miscellaneous records handwritten during the patient encounter The patient is discharged and all the paper, plus the electronic records that have been printed are gathered by the staff in the Health Information Services department and brought across the street for processing by the ChartMaxx Team

The functions of the ChartMaxx Team Prepping – removing all the paper documents that have interfaced directly into ChartMaxx Scanning – all of the handwritten pages that have no electronic version Quality Reviewing – ensuring that each document has superior scanned quality, ensuring that each page belongs to the patient, naming each document that does not have a bar code – we have 767 document types Completing this task for all of the inpatient and outpatient records collected on a daily basis

It is collected in one place, now what??? All authorized users now have access to the record at one time for new encounters, payment reasons, quality review aspects, and patient requests for information We have authorized users consisting of MDs, nurses, therapists, business office staff, physician office staff, outside auditors – coding and billing

What about before ChartMaxx?? Records at CVMC are kept forever Records start in 1967 and were microfilmed either on roll film or fiche until 1995 Some records are stored at a facility in the original paper format – 1995 through through 2004 on a hard drive 2004 to present on ChartMaxx

Sometimes we are just like

Other 21 st century responsibilities… Release of information for all attorneys, continuing care, disability, etc. Governmental releases CCME, CMS, and RAC (Recovery Audit Contractors) Cancer Registry ICD-10 is just around the corner – the USA lags behind the rest of the world Privacy Officer issues, audits, and reports Regulatory agency requirements: the Joint Commission, Centers for Medicare and Medicaid Services, American College of Surgeons, the Office of Civil Rights

Even with 21 st century innovations– The patient and the care they receive is central to everything Health Information Managers do. Complete and accurate medical records, no matter the format, translate into the safest, most effective patient care for this visit and all subsequent visits, whether at Catawba Valley Medical Center or at another facility.