HIM Guidelines to Facilitate Integration
In this assignment, you will imagine that you are the Director of Health Information Services at LiveWell and that your HIM department is responsible for:
· Release of Information
· Electronic Document Management
· Coding
· Transcription
· HIPAA Privacy
The scenario explains that several clinics have merged at LiveWell under the same corporate entity and that, as a part of your responsibilities, you must develop a plan which manages HIM functions through the Healthcare Integration Process. Ultimately, the LiveWell Integrated Health System (LIHS) will need consistent policies written and modification of some procedures.
For this assignment, you will need to complete instructions below:
This assignment has three (3) steps. Steps 1 and 2 provide necessary background information and Step 3 describes the details of your assignment.
Step 1: Overview of the Tasks
Imagine that you are the Director of Health Information Services at LiveWell. As part of your responsibilities, you must develop a plan which manages HIM functions through the Healthcare Integration Process. Several clinics have merged at LiveWell under the same corporate entity. The HIM department is responsible for Release of Information, Electronic Document Management, Coding, Transcription and HIPAA Privacy. LiveWell Integrated Health System (LIHS) will need consistent policies written and modification of some procedures.
To organize your plan, you created Table 1, below. Review the contents of Table 1 and take note of the items which have been crossed-out; these indicate tasks which have already been completed. As you can see, the Release of Information tasks (outlined in red) still need attention.
Table 1
| HIM Dept.Function | Goal | Tasks/Status |
| Electronic Document Management | · Standardize all Medical Record formats to 6 digit for MagicHealth EHR.· Organize Electronic data from all sources for placement intoMagicHealth. | 1) 6 digit all numeric format rolled out.2) All sites up to date with 6 digit format for new appointments/patients.3) Policy and procedure written and distributed to all sites. 4) Documentation Guidelines updated and distributed.5) Education to all sites: review of policies/procedures/guidelines. |
| Coding | · Merge all coding under one manager.· Incorporate Professional Fee [Profee] coding from acquired clinic locations. | 1) Identify coders with Profee experience. Test and identify coders. 2) Select lead Profee coder.3) Centralize coding in existing HIM department using old paper file room.4) Modify room, order and place furniture and supplies. 5) Hire staff.6) Write Profee coding procedures.7) Update policies to include coding expansion. |
| Transcription | · Absorb transcription from acquired clinics into existing outsourcetranscription volume. | 1) Meet with Outsource Transcription Company. 2) Provide acquired clinic report examples.3) Designate date for absorption of acquired clinic reports.4) Roll out clinic transcription to outsource company |
| Release of Information | · Centralize all ROI at LiveWell.· Merge ROI to have one overseeing manager. | · Observe ROI practices at each acquired clinic location. (Task completed – See Table 2 below) Write guidelines that include:A. Prepare a step by step process for ROI between acquired clinics.1. Communicating between Clinic locations on ROI requests2. Logging /Tracking Requests3. Tracking Types of Requests: patients, subpoenas, doctors, insurance, etc.4. Distribution of Records to be released.B. Considerations that might impact the guidelines: HIPAA Privacy, Security and Confidentiality, Mental Health and Alcohol/Drug Treatment Records, Disclosure Tracking – HIPAA |
HIM Guidelines to Facilitate Integration
Step 2: Results of the ROI Observations
Table 2 (below) represents the results of the ROI observations conducted at the various clinics. These clinics have varied processes, and sometimes incomplete processes. Review the Table 2 results below.
Table 2
| Name | Medical Record Format | MR#Example | Specialty | |
| ROI Observations Made by HIM Director | ||||
| DurHealth | 4 numeric digits | 4578 | Pediatric | Patient’s mother asks for a school physical report for the football coach at school. Office clerk gives mother a Release of Information form; mother fills it out with names and phone numbers. Clerk logsthe request and faxes the physical to the coach. |
| MorHealth | 6 numeric digits | 015896 | Internal Medicine and Urgent Care | Patient asks for a two copies of her lab result – one for her adult daughter who is a nurse and another copy for her nephrologist. Office Manager prints a copy, tells patient to give it to her daughter. Patient is then sent to the ROI office to get the copy for her nephrologist. ROI office willsend copy directly to the nephrologist. |
| Dr. Behrens Office | 3 alpha (1st three of last name, 4 numeric (month and year DOB) | Gar0161 | Family Practice, Behavioral Health | Patient requests copy of record for her MD in Florida who she sees over the winter. Office Nurse opens EHR, prints summary documents from March of current year to October including the ER visit in July and the visit to MorHealth urgent care. Gives them to patient in an envelope for FloridaMD. |
| ForHealth | 6 numeric | 410255 | Pediatric | Receives subpoena for records on a child abuse case, hands the subpoena to the doctor atForHealth. No further action is known. |
| RocHealth | 6 numeric | 885547 | Family Practice | Patient asks for current visit and previous visit to ER to be copied and sent to orthopedic surgeon out-of-town. She also asks for her son’s immunization record for the school he goes to now. Office scheduler prints it all and faxes it toboth locations. |
Step 3: Assignment Details
Map a centralized ROI function for all facilities at LIHS. To complete this, refer to Column 3 in Table 1 (above) , where you will see “Write Guidelines that include:” which should guide your mapping.
1. The map will ensure that a smooth, proper function has been set up across all clinic locations so that ROI is centralized in the LiveWell HIM/ROI office.
2. Address various types of releases, for example continuing care, personal copies, etc. (refer to Column 5 in Table 2 to guide you).
3. Be certain that the map abides by applicable laws and regulations that pertain to release and exchange of health information (HIPAA, Subpoenas, etc.).
4. You may find the article attached below is a good resource to assist you in completing your mapping.
Your submission should:
1. Be submitted in a Word Document, 2 pages in APA format.
2. Include citations and resources as appropriate.
3. Be proof-read, spell-checked, grammar-checked, etc.
