Reference no: EM133597475

Case: 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 post discharge. 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, make up 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.