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Consider ways in which a hybrid or electronic record could affect compliance with IM.02.01.03

HIM Connection, February 3, 2009

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The 2009 Joint Commission standards may pose unique challenges for hospitals with hybrid or fully electronic records, Kathleen Catalano, JD, RN, director of healthcare transformation support for Perot Systems, and Pat Brown, RHIA, vice president of HIM services and privacy officer for Pyramid Healthcare Solutions said at the October 12–15, 2008 80th annual AHIMA conference in Seattle.

Directors should also ask several questions during an EHR implementation to ensure compliance with IM.02.01.03, specifically EPs 6 and 7, which pertain to loss, damage, unauthorized alteration, unintentional change, and accidental destruction of health information. The questions include the following:

• How will we ensure that the information we release is final?
• When will we deem an episode closed? Will it be automatic, or can we specify a date?
• How will we know that someone has changed information in a record? Will we receive a report or some other sort of notification?
• Who will we permit to destroy health information?

Editor’s note: This tip was adapted from the February issue of Medical Records Briefing. For more information, click here.

Hybrid records and legal holds
Joint Commission compliance isn’t the only challenge that hybrid records pose. Legal holds—the process of preserving and sequestering all documentation related to potential litigation—can also be complex when dealing with a hybrid record. To learn more, sign up for HCPro’s February 18 audio conference “Performing Legal Holds in a Hybrid EHR Environment.”

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