Importance of medical records management intensifies in high-tech world
Health information management, which includes the management of medical records, is a field that is evolving with advances in technology.
“Health information is an exciting career,” said Julia Kendrick, regional health information management director for SSM Health Care Oklahoma. “This industry has come a long way from the days of us being known as the ‘medical record librarians’ to where we are today.”
Accuracy of medical records has always been a concern, but the rise of electronic medical records has brought about different quality issues.
“The electronic medical record does give us challenges providing a concise and clear picture of the patient’s stay,” Kendrick said. “While the conveniences that our EMRs provide – through templates, the ability to cut and paste, drop-down menus and flow sheets – are wonderful tools to assist us in documentation, there is potential for those conveniences to impact our quality. It’s very easy to be going through a drop-down menu and accidentally click on the wrong one.”
In her role, Kendrick identifies problems, then takes steps to reduce their likelihood of reoccurring.
“We review a significant amount of medical records, looking at opportunities to better document issues,” she said. “Additionally, we look at identifying areas of opportunity to provide education to physicians or other clinicians on how they can improve in their documentation.”
Much of this review happens in cases when claims are denied, which helps health information management professionals identify documentation areas that need improvement.
“When I first started in 1992, we were doing the exact same things, looking at documentation, making sure that the story was complete,” Kendrick said. “We were just looking at paper documents instead of an electronic document.”
However, she said patient record security and patient privacy have improved with the transition from paper to electronic records.
“We have a better tracking mechanism to determine who has access to records,” she said. “With most EMRs, every action that someone takes when they are in the system is logged in the audit trail, so that is significant. We have (fewer) opportunities for lost records.”
Patient portals have been a great feature of electronic medical records, providing the patient with details such as lab and X-ray results, reminders about appointments and the ability to communicate with nurses and physicians.
“That is a tremendous asset for our patients,” Kendrick said. “It has allowed the patient care experience to be extended out past their visit or discharge date.”
It can be expected that the use of patient portals will increase and the capabilities of these portals will expand.
Electronic medical records also make it easier for staff members to respond when a physician’s office needs information, Kendrick said.
“We can do it faster because we don’t have to go and hunt down paper charts; the information is all right there at our fingertips,” she said.
Communication of electronic medical information from a physician-to-physician standpoint, though, could be smoother, she said.
“Moving forward, I see the possibilities of the health information exchanges expanding,” Kendrick said. “Our electronic health records give us the foundation of being able to have continuity of care across states and remove some of the barriers to sharing information on a patient or giving the patient the ability to have one medical record instead of multiple.”
The Office of the National Coordinator for Health Information Technology is tasked with coordinating nationwide efforts in the exchange of medical information using the most advanced technology available.
“We have many examples of how health information technology can decrease errors and improve quality, but we also have examples of how it can result in just the opposite,” said Dr. Andrew Gettinger, the federal agency’s chief medical officer.
“Many of the problems experienced are a result of poor implementation or challenges that other practices and organizations have solved,” Gettinger said. “It’s important for us to share these examples of best practices and regularly engage with others across the health care system, both within government and in the private sector, to reduce these issues that may result in concerns while helping them implement health information technology tools that clinicians of all types can’t imagine practicing without.”
Providing professional support and resources to health information management professionals to overcome challenges is the goal of the American Health Information Management Association, which has been in operation for 90 years.
“How we meet any challenge is to, first of all, stay current for our members so that they have the tools and the information they need to do the very best job as a professional in this field,” said AHIMA Information Governance Director Robyn Stambaugh. “Also, to be an advocate for the members so that they are prepared for what is coming in the future.”
One area of AHIMA’s focus is helping members fully understand security and privacy concerns.
“AHIMA has always been actively involved in making sure that HIM professionals have a good understanding of their role in privacy and security and release of information,” Stambaugh said, “making sure that we meet all the regulatory standards, compliance standards, federal and state mandates, with HIPAA being one of those. As custodians of the record, it is our responsibility to make sure that information is accurate and trustworthy, that we are protecting it and securing it to the best of our ability, that we are processing it and using it correctly, and that we are retaining it or disposing of it as well and there are a multitude of things that happen in all of those parts of the cycle.”