Reader feedback

Hello everyone,

I just wanted to reach out and ask each of you how you feel about the stories in MRB. What topics are of interest to you? What specific topics would you like to see covered in upcoming issues?

Also, please feel free to reach out to me any time you have a sample tool or form you are able to allow us to reprint in the newsletter. I think it's really great to include sample items for each of you to reference and re-purpose.

I'd love to hear your story. If there's something exciting or innovative happening at your organization and you or someone you know are willing to talk about it, please email me and we can get started on a story for MRB. And remember, we also accept submissions from readers.

I look forward to hearing from you.

Best,
Jaclyn Fitzgerald
Editor, Medical Records Briefing
Email: jfitzgerald@hcpro.com
Phone: (978) 223-1741

Comments

  • edited May 2016
    How about Data Integrity and the Electronic Record? What role has the HIM Professional taken as it relates to ensuring completeness and accuracy in electronic documentation?

    Thanks

    Maryellen

    Maryellen McGowan, MS, RHIA, CPC
    Director Of Health Information Management
    & Clinical Documentation Improvement
    Winthrop University Hospital
    259 1st Street
    Mineola, New York 11501
    (P) 516-663-8901
    (F) 516-663-2729
    E- Mail: mmcgowan@winthrop.org
  • edited May 2016
    With the implementation of the EMR spurred on by MU incentives ( and penalties), many hospitals and physician practices scrambled to implement. I am very interested ( and concerned) regarding how the following have been operationalized and risks mitigated:

    1. How are hospitals managing the hybrid record ( parts on paper and parts electronic)
    2. How are hospitals managing multiple EMRs that make up the legal health record. For example, at our hospital, we currently have 5 separate systems that make up the record, plus the paper component. This is a real nightmare trying to manage and keep straight.
    3. Error corrections - from an operational standpoint, how are you managing these, most EMRs do not allow you to mimic the paper process, rather the error is buried in meta data , unable to be viewed by the provider
    4. Policy on copy and paste, pulling forward documentation - who is the real author of this data, is it correct for the visit being pulled forward
    5. Access to the EMR - do you have a clear cut policy on role based access
    6. Release of information from the hybrid record.
    7. EMR that do not have interface to allow flow of information


    Last ,and most important, what is the role of the HIM professional, is their knowledge and skill utilized to the fullest ? Are they guiding forces in the implementation ?


    These are just some of my observations. I support EMRs 100 % but have seen many issues with implementation. I would love to hear success stories on how the above issues are managed.

    Thanks

    Betty



    Elizabeth MacInnes, MHA, RHIA, CPHRM
    Vice, President, Quality
    Portage Health
    Hancock, MI 49930
    906-483-1504 work
    emacinnes@portagehealth.org
  • edited May 2016
    One of the items that has recently come up and caused some consternation in my organization is that due to meaningful use, dictation is going away. Its really a political move by our IT leadership to move more physicians into using PowerNotes and PowerForms (we are a Cerner shop). We've had to dispel this notion on numerous occasions and it all boils down to interpretation of meaningful use definitions. It would be great if more was written about this topic. We recently conducted an internal audit with physicians who say that dictation "paints" the better story of what's happening with and to the patient vs. PowerNote and PowerForm derived documentation.

    Stacey McIntosh, MBA, MAOM, RHIA, CHP, CCS
    Manager, Health Information Management
    Memorial Hermann Health System
    909 Frostwood, Suite 2:205
    Houston, TX 77024
    (o) 713-338-5975
    (f) 713-338-4542
    Stacey.mcintosh2@memorialhermann.org
  • edited May 2016
    Excellent and that is what I mean by Data Integrity. Providing policies addressing Copy and Paste and also Destruction would be extremely helpful.

    Maryellen

    Maryellen McGowan, MS, RHIA, CPC
    Director Of Health Information Management
    & Clinical Documentation Improvement
    Winthrop University Hospital
    259 1st Street
    Mineola, New York 11501
    (P) 516-663-8901
    (F) 516-663-2729
    E- Mail: mmcgowan@winthrop.org
  • Thanks for the great ideas, everyone. We have the four-page EHR Briefings in quarterly issues, but it sounds like we need to cover EHRs more frequently.

    Feel free to reply to this thread or email me directly at any time with ideas, feedback, etc.

    Thanks!
    Jaclyn Fitzgerald
    Editor, Medical Records Briefing
    jfitzgerald@hcpro.com
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