From Hybrid to Fully Digital System
(HIM 101)
, 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 electronic 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.