Introduction: The health record is a form of communication between internal and external
stakeholders in the healthcare environment. Health informatics professionals are
responsible for managing health records whether in paper, electronic, or hybrid format.
Guidelines must be followed in maintaining records, including their storage and
destruction, and policies must be evaluated for their compliance with state and federal
regulations. STOP INFO HERE.
BEGIN Task HERE:
A. Discuss how you would manage the use of paper forms in a hybrid environment in order
to maintain the integrity of the health record.
- Compare the strengths and weaknesses of using hybrid records.
- Discuss legal issues that may arise when using hybrid records.
B. Evaluate the attached “Willow Bend Record Policy” to determine if it protects health
information for record storage and destruction of paper and electronic health records
based on the following: - Washington state regulations
- Medicare Conditions of Participation
- Health Insurance Portability and Accountability Act (HIPAA)STOP assignment here.
See Notes below
C. If you use sources, include all in-text citations and references in APA format with Works
Cited.
Healthcare Record
The integrity of health records refers guarding the records to ensure that they are tamper-
proof. The use of a hybrid system to maintain health records poses many challenges to the
integrity of records and caution must be exercised to safeguard the integrity. The use of both
electronic and paper media to store health records in a hybrid environment can create
inconsistencies such that the identification of official records to be used (whether paper or
electronic) at any given time may be impossible. One way to effectively manage paper records to
ensure the integrity of health records is performing an audit trail. An audit trail ensures that any
alterations made to the paper health records are easily identifiable. Moreover, the person who
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made the alteration and the date of alteration are also identified. In addition, maintain a separate
original copy of the health record is a crucial management tactic to ensure that even when an
alteration has been made, the original copy is accessible.
Using a hybrid records has both strengths and weaknesses that may either facilitate
proper healthcare service delivery or hinder it. One strong point of using hybrid records is that it
allows healthcare professionals time to transit to electronic records without tampering with
healthcare delivery. The healthcare providers can provide their services to patients while slowly
transferring data to the electronic system. Secondly, since time is available for transition, good
policies to safeguard the security and integrity of the records can be created without tome
pressure. The ample time provided by the hybrid system ensures quality policies for the
electronic record system and healthcare service delivery. On the other hand, hybrid records can
cause service delivery delays when improper guidelines as to which records are the primary
medical records (paper or electronic). The use of hybrid records increases the risk of
unauthorized access to medical records since the medical practitioners will be expected to
maintain security for both electronic and paper health records. This may compromise the
integrity of the health records (Diminick, 2008).
When using hybrid records, there are several legal issues that may become apparent. One
such issue is the availability of information to authorized users. The law requires that a health
institution avails information in a timely manner to authorized users. When attorneys requests for
health records that relate to a pending litigation, hybrid records prove problematic. The problems
arise because the information required date back in the past and retrieving the information from
paper records may be time consuming. Moreover, the attorneys may become problematic by
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requesting explanations regarding reasons for having some records being in paper while other is
in electronic format. Apart from attorneys requesting for medical information regarding
litigation, patients may require access to their healthcare information as allowed by the law.
Locating this information might be very difficult since the information may be spread across
media. When Health state department requires some specific documents urgently, it becomes a
big problem locating the document. Moreover, quality reporting becomes a problem because
locating documents containing specific data that is required in reporting is very hard when using
a hybrid system.
Willow Bend Hospital has complied with Health Insurance Portability and Accountability
Act (HIPAA) with regard to protecting, storing and destroying medical records. HIPAA requires
health institutions to put in place policies and procedures that govern the access of protected
medical records. It directs that only specific employees should access the records. At Willow
Bend Hospital, only a designated employee has the authority to access and destroy medical
records whose time of destruction has come. Moreover, willow Bend Hospital policies for
physical safeguard are consistent with those laid down by HIPAA. HIPAA requires that a
healthcare institution should have policies and procedures for removing software and hardware
from the hospital system. The hardware and software must be removed from the system and
disposed in a manner that may not compromise protected health information. At Willow Bend
Hospital, the hard drive of a computer is physically removed and destroyed when it has
malfunctioned and cannot be formatted. Moreover, Compact Discs that have been used for Apes
Patient folder are destroyed physically while being supervised by the director of Health
Information Management Department.
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Willow Bend hospital’s policies for healthcare records are also consistent to some extent
with those found in the state of Washington. With regard to retaining health records for patients,
the state of Washington has designed laws that requires health institution store and retain health
records for at least 10 years after the recent discharge of the patient from the hospital. This
provision is consistent with those found in Willow Bend Hospital that requires retention and
maintenance of healthcare records for 10 years for most of the healthcare information. The
consistence found in these laws and policies are meant to protect and safeguard the integrity and
privacy of patient’s health records. All the laws restrict access to the information and provide
safe avenues for destroying the information upon its expiry (Health Information and the Law
website, 2012).
One of the requirements that healthcare organizations must meet to be eligible to
participate in Medicare programs is proper maintenance health records (American Health
Lawyers Association, 2012). Center for Medicare requires healthcare institutions to have
administrative responsibility for healthcare records. This is similar to the policy being used at
Willow Bend Hospital where the director of Health Information Management Department has
the responsibility of overseeing the destruction of healthcare records. The Medicare center, like
Willow Bend hospital has a time frame within which health records must be maintained. Unlike
Willow Bend Hospital, Medicare center requires health institutions to maintain both in-patient
and out-patient medical records for at least five years from the last discharge. The information
maintained within the five years must be protected from an authorized access. This restriction is
also similar to that used at Willow Bend hospital where only designated employees can access
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certain medical records. The bottom line in the restrictions created by Medicare center is to
ensure that healthcare organizations maintain proper records (Wilson, 2006).
A comparison of healthcare records as stipulated by the state o Washington, Medicare
conditions for participation and Health Insurance Portability and Accountability Act indicates
that Willow Bend hospital policies are aimed at protecting, retaining and destroying medical
records in accordance with the law. The provisions found in each regarding the safety and
integrity of health record is a clear indication that Willow Bend hospital is in line with the
provisions of the law. Although there are some few variations such as the number of years
required before termination, the aim is one. Therefore, all these regulations put in place by
Willow Bend hospital to protect health information for record storage and destruction.
References
American Health Lawyers Association. (2012). Medicare Conditions of Participation
(Conditions for Coverage).
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Diminick, C. (2008). Record Limbo: Hybrid Systems Add Burden and Risk to Data Reporting.
Health Information and the Law website. (2012). Federal Laws.
Wilson, J. (2006). Health Insurance Portability and Accountability Act Privacy rule causes
ongoing concerns among clinicians and researchers. New York: John Wiley & Sons.