Health Information Management

Know how an EHR could affect your accreditation survey

HIM-HIPAA Insider, December 8, 2009

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When a surveyor comes knocking on your door, you had better have a plan in place to grants access to your EHR. Staff members also must be ready and willing to answer surveyors’ questions about navigating your EHR and locating specific information.
 
CMS has published a policy memo (S&C-09-53) reminding hospitals of their obligation to provide surveyors with unrestricted access to the EHR. The policy memo, issued in August, aims to ensure that surveyors will be able to “conduct the survey process in a consistent manner in all facilities regardless of whether the facility uses paper-based records and/or EHRs.” The memo details provider/supplier responsibilities and surveyors’ responsibilities during the survey process.
 
The memo states that when a surveyor requests access to an EHR, the facility must:
  • Provide a tutorial that explains how to use the system.
  • Designate an individual who, upon the surveyor’s request, will access the system, respond to any questions, or help the surveyor access electronic information in a timely manner.
  • Provide the surveyor with immediate access to a computer terminal when requested.
  • Provide surveyors with direct print capability or make available a printout of any record or part of a record immediately upon request. (Surveyors should make reasonable efforts to avoid printing entire records. They should print only portions of records necessary to support findings of noncompliance unless protocols for particular types of surveys require otherwise, according to the memo.)
  • Provide surveyors with electronic access to records in a read-only or other secure format to avoid any inadvertent changes to the record.
  • Ensure the confidentiality of patients’ or residents’ clinical records.
Prepare cheat sheets for surveyors that outline electronically stored information and note its location, says Kathleen Catalano, JD, RN, director of healthcare consulting at Perot Systems in Plano, TX. Draft one for closed records and another for open records. As with a paper record, quick access to documentation is necessary, and surveyors need to know the order in which documents will appear.
 
Editor’s note: For more tips, view the December 2009 issue of Medical Records Briefing.



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