Submitted by the Tennessee Health Information Management Association
Intent
This resolution is intended to advance AHIMA's commitment to being a leader in the management of health information for patient care, quality measures, reimbursement, and all other uses. While standards are being developed and adopted that address the technology of health information, electronic health information practice standards are needed to guide the management of health information in an electronic environment.
Here are some examples of areas where practice standards are needed:
- Establishing a closed health record in an electronic environment
- Making amendments/addendums/corrections to the electronic health record
- Managing the migration of data into an electronic health record
- Correcting lab results in the electronic health record
- Correcting dates of service
- Correcting/merging patients' records (duplicate medical records; reports on wrong patients' record)
- Importing of lab/med/allergies/problems to physicians' notes
- Appropriate use of "cut and paste"
- Management of electronic forms/templates: development, indexing/categorizing, inventory, approval, revision
- Appropriate inclusion/use of patients' photos
- View only/sequestering
- Auditing for privacy violations - volume, focus, frequency
- Use of electronic record to prevent/identify identity thief
- Alerts in electronic record - advanced directives, power of attorney, other legal documents
- Verbal orders in electronic record
- Patient completed forms; patient input on medication lists
- Patient communication/referring physician communication
Preamble
Whereas, The healthcare industry is migrating and evolving into an electronic environment with the adoption of electronic health records;
Whereas, The successful implementation of electronic health records requires extensive changes in traditional HIM practices;
Whereas, Criteria and standards for technical functionality are being developed by a variety of groups (CCHIT, HITSP, HL7, etc);
Whereas, The criteria and standards do not address best practices or guidelines for certain HIM functions, (i.e., amending, correcting medical record entries, archiving original text);
Whereas, HIM professionals are responsible for the integrity, reliability, defensibility, and maintenance of the legal health record, regardless of its format; and
Whereas, The HIM professionals are required by the AHIMA Code of Ethics to "Preserve, protect, and secure personal health information in any form or medium and hold in the highest regard the contents of the records and other information of a confidential nature, taking into account the applicable statutes and regulations";
Therefore, be it
Resolved, That AHIMA convene qualified workgroups of HIM professionals and other identified stakeholders as appropriate to examine and evaluate existing criteria and standards to determine areas of HIM practice in which professional guidelines are needed;
Resolved, That AHIMA convene qualified workgroups of HIM professionals to develop professional practice standards where needed;
Resolved, That AHIMA will devote necessary resources, including, but not limited to, providing speakers/topics for programs of allied healthcare professions, to promote establishment of these professional standards as expected practice within the healthcare industry; and
Resolved, That AHIMA will publish a registry of e-HIM practice standards in the public domain.
Approved by the 2007-08 House of Delegates, October 7, 2007, Philadelphia, Pennsylvania