Document Management, Imaging Processes Toolkit Supports EHR Implementation
AHIMA has published a new toolkit, “Document Management and Imaging,” that serves as a guide for HIM professionals developing document management and imaging processes for the implementation of an electronic health record (EHR).
Developed by an AHIMA volunteer workgroup, the toolkit focuses on document imaging operations and best practices that help support EHR adoption from the beginning stages to ongoing efficiency following implementation.
“In today’s quest for a fully integrated EHR, document management and imaging still plays a critical role,” said AHIMA CEO Lynne Thomas Gordon, MBA, RHIA, CAE, FACHE, FAHIMA, in a press release. “Knowing how to manage paper records throughout their lifecycle is critical to the success of EHR adoption.”
The development and implementation of a document management system (DMS) provides opportunities for organizations to achieve greater efficiency and reduced cost by making these paper documents accessible from the EHR. It is important to include HIM professionals in this process since they ensure that the organization’s HIM processes and integration points in the EHR are properly incorporated into the DMS strategy being developed.
The toolkit excerpt below includes insight into keeping HIM professionals involved with the DMS implementation strategy and processes.
HIM professionals must be included in the DMS enterprise-wide strategic plan to ensure that HIM standards of practice (including regulatory requirements) are met as the organization is crafting its strategy for years to come. The following questions that pertain specifically to the HIM department should be considered as the overall institutional DMS strategy is developed:
- What are the long-term goals for the following HIM processes?
- Defining and maintaining the designated record set (DRS) and legal health record (LHR)
– Accuracy, integrity, and accessibility of information
– Chart retrieval and viewing
– Document capture
– Chart completion, including electronic signature and deficiency management
– ROI, including printing and exporting guidelines
– Coding, abstracting, and migrating to ICD-10-CM/PCS
– MPI maintenance
– Storage, retention, and destruction
– Downtime or contingency planning
– HIPAA, Joint Commission, CMS, and other regulatory compliance
– Document management and information obligations imposed by health information exchange and accountable care organizations
- How do these HIM processes relate to clinical systems? For example, how will verbal order signatures be tracked, who will track them, and what impact will this have on computerized provider order entry (CPOE) systems?
- How are documents created, generated, and transitioned for CPOE implementation?
- What are the organizational goals surrounding decentralized versus centralized scanning?
- How will seamless integration with clinical systems be achieved?
- What HIM requirements are included in the organization’s clinical health information systems and how will these be incorporated into request for proposals (RFPs) and procurement processes?
- What plans are instituted to promote physician and other clinician acceptance of organization-wide electronic document management? For example, will DMS functionality require online medical record access and chart completion?
The toolkit is free to AHIMA members. To access the full toolkit, available as a digital download, visit www.ahimastore.org.