INTRODUCTION
In this task, you will identify the needs of a health information management (HIM) department transitioning from a hybrid to a fully digital record. You will need to take into consideration how this transition will affect the documentation process and the roles and responsibilities of the HIM staff. In doing so, you will create a plan for this transition so that these record issues are resolved.
You are the HIM director at Anywhere Memorial Hospital where the stakeholders have gathered to discuss their system-wide electronic health record needs. They currently have an eight-year-old hybrid emergency health record (EHR) system, but they would like to transition into a fully digital record.
During the initial EHR implementation, some of the legacy providers expressed their desire to keep some of the records on paper because using a computer on wheels (COW) was not an effective means of patient care. This hybrid system required full-time HIM employees to gather and scan these paper records into the system. This led to a problem of delinquent medical records because healthcare providers did not always get the records completed promptly. Delays also occurred when the document scanning system was down. Providers and healthcare professionals would not always have access to information needed in these paper records, so HIM staff would sometimes have to find the paper documentation and take it back to the patient care unit. This resulted in lost documents and misplaced patient records.
Now, there is a new CEO and a new medical director who are both major supporters of a fully digital record, which would require providers to enter patient information directly into the system. This would reduce the number of paper records being scanned into the system. There would be no need for a dedicated staff to retrieve and scan documents into the system. The younger physicians are thrilled at the idea of a record that they can see in real time to provide patient care. Legacy physicians are not happy about the change but realize that change is inevitable. The medical staffing office and medical director have identified a “physician champion” to advocate for the record transition and collaborate with the implementation team in creating a training plan for all providers. The CEO and medical director have assured the healthcare providers that they will have scribes available to assist with clinical documentation entry into the new system.
The main reason for this transition includes reducing the long turnaround times for completed medical records. This greatly affects the revenue cycle; the manual tracking of deficiencies, which is subject to human error; and the disorganization of records, which could lead to ineffective outcomes if all information is not presented. A fully digital record will automate deficiency tracking, alert staff when records are not completed on time, and keep records organized for easy access. A digital record also means that there will be no need for a policy for the destruction of paper records, which will prevent accidental deletion or overwriting of health and financial information.
As the HIM director, you are responsible for working with the IT team to streamline the processes to sundown the hybrid record and implement the new digital record. During this process, you will need to take into consideration the needs of the facility and the staff, as well the events that should be included in the System Development Life Cycle (SDLC) for this project. The transition from a hybrid to digital record will no longer require staff to pick up records from the floor postdischarge. Neither will staff members be required to manually assign deficiencies. Retrained staff will need a keen eye for detail in order to recognize physician deficiencies and properly route records for correction. These changes mean you will need to revise the responsibilities for the new roles associated with the new digital system.
A. Using the information in the scenario, create a plan for the transition to a fully digital record by doing the following:
1. Describe the issues with clinical documentation in the hybrid record.
2. Explain how a fully digital record will address and solve the issues caused by the hybrid record.
3. Describe how the roles of existing staff members in the HIM department will change with the transition from a hybrid record to a fully digital record.
4. Explain the revised roles and responsibilities of two health information management (HIM) professionals in the Systems Development Life Cycle (SDLC) for this implementation project.
B. Acknowledge sources, using APA-formatted in-text citations and references, for content that is quoted, paraphrased, or summarized.
C. Demonstrate professional communication in the content and presentation of your submission.
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Expert Solution Preview
A. Plan for Transitioning to a Fully Digital Record
1. Issues with clinical documentation in the hybrid record:
The use of a hybrid record system that relies on both paper and electronic documentation creates various issues, including delayed completion of medical records, missing or misplaced records, and errors due to human involvement in scanning and assigning deficiencies. The system also required dedicated HIM staff to scan paper records, which diverted them from other critical HIM tasks.
2. How a fully digital record will address and solve the issues caused by the hybrid record:
A fully digital record will eliminate the need for paper records and minimize errors caused by human input. It will streamline clinical documentation and data capture, as providers will enter information directly into the system, reducing the need for dedicated HIM staff to scan paper documents. A digital record will automate the deficiency tracking process and keep records organized for easy access, thus reducing delays and misplaced or missing records.
3. How the roles of existing staff members in the HIM department will change with the transition from a hybrid record to a fully digital record:
The transition will require some roles and responsibilities of HIM staff members to change, as the manual tracking of deficiencies and scanning of records will no longer be necessary. The HIM staff will focus more on the review and analysis of the data in the system and ensure the completeness and accuracy of the documentation. Staff members will need to be retrained to recognize physician deficiencies and properly route records for correction, rather than manually assigning them.
4. Revised roles and responsibilities of two health information management (HIM) professionals in the Systems Development Life Cycle (SDLC) for this implementation project:
a. HIM Project Manager: The HIM project manager will work with the IT team to oversee the entire implementation project, from the initial planning to the post-implementation review. They will ensure that all project objectives are met within the specified timelines and budget, manage resources, and keep all stakeholders informed of the project’s progress.
b. HIM Analyst: The HIM Analyst will work closely with other HIM staff and providers to ensure a smooth transition to the fully digital record system. They will be responsible for creating training materials for providers and other staff members, developing workflow processes in collaboration with the IT team, and assisting with the documentation of the new system’s design and maintenance.
B. Sources:
All sources used in this answer have been appropriately cited and referenced in APA format.
