Health Information Management

1. Health Information Management 2008 PEBLO/PAD Conference Susan M. Pierce, RHIA, CHPS, CMT Director, Health Information Management Bureau of Medicine and Surgery 2300 E Street NW Washington, DC 20372-5300 (202) 762-3162

2. Issues • Disposition of Medical Records • Errors In Retiring Records • Late Flowing Documents - Eliminating Loose Chits • Backlog & Effects of this Backlog • The Hybrid Medical Record • HIPAA/PHIMT Disclosure • AHLTA

3. Disposition of Medical Records • Service Treatment Record (vs. HREC) • New name for active duty outpatient records • Congressional interest • Separation/Retirement of AD members and De-activated Reserves • Policy: Send to PSD. PSD must send to VA within 5 days of receipt; VA to have record 30 days post separation. - Analyze the record to ensure completeness • Develop a tickler system • Keep a tracking system/log • Date, Patient Info, Address to, Person who mailed it, Mail Tracking # (UPS/FEDEX/Certified mail return receipt)

4. Disposition of Medical Records: Records and Claims • Active Duty • Veterans benefits • Billing other services for care • Some AD have other health insurance through a spouse • Motor vehicle accidents • ER Records • MTF may not be using AHLTA • What is your MTF’s policy? • All other patients • Documentation is key in resolving claims • If care is rendered at your MTF, MTF has the responsibility of having the documentation in house.

5. Common Errors in Retiring Records • Retiring records before your loose filing is up to date. • Incorrect File Names – It should contain all required digits and extensions on the filenames must be .R01 for the Record Index file and .S01 for the Shipment Data File. • Note: Fetal Monitoring Strips are labeled with the infant’s name ( Chap 16-67). FMS must be in a separate folder.

6. Common Errors in Retiring Non-AD Records • MTFs forward records to National Personnel Records Center (NPRC) with the old method using SF 135 or sometimes without any type of index. • Extended Ambulatory Record and Fetal Monitor Strips are not created in the Inpatient file room; therefore, they are not included in the index. • Some records listed in the index are not in the box.

7. NPRC is moving! • Letter from NARA dated May 6, 2008 • 4 million cubic feet of records • Last day to receive transfer numbers before the move is May 29, 2008. • Shipments from your facilities must arrive NLT 8/29/08. • No numbers will be assigned through 10/14/08.

8. New Address • Beginning 10/14/08, all SF135s and all record shipments with approved transfer numbers will be sent to this new address: National Personnel Records Annex 1411 Boulder Drive Rock City Industrial Center Valmeyer, IL 62295 POCs • Military Records: Charles Mucho 314-801-9159 • Civilian Records: Rhonda Weedman 314-801-9237

9. Late Flowing Documents - Eliminating Loose Chits • Late Flowing Documents - Eliminating Loose Chits • The Importance of a “unit record” • Command support for your record keeping procedures. • Setting a good example. • SF600s and AHLTA downtime. • Full name, FMP + SSN on every page. • Record accessibility when needed.

10. Lost Records/Loose Reports • Forward all lost records/loose reports where the record is maintained. - check CHCS - check DEERS - request duty stations of AD members from Navy Locator/Navy Personnel Directory Note: Do not mail old documents to the VA without confirming that they indeed have records for the same individuals.

11. Disposition of Medical Records: Do you have a backlog? • Identify and quantify your backlog • Do you have branch clinics? • Number of records in jackets • Filing inches of loose chits • Separate by category (AD, Reserve, Dependents, etc.) • Sort and disposition according to category • What created your backlog? • Root cause analysis • Develop a plan • Shadow records • Should not contain any original documentation • If originals are found, file in the primary record

12. The Way Ahead The Services agreed to adopt the following policies to prevent back log and assure timely transmittal of records: 1. MTF staff will no longer forward HTRs or components thereof directly to DVA. Instead, MTF staff will forward the HTRs or components thereof to the appropriate Military Service personnel enter when those records are complete, or not later than 30 business days after separation/retirement, whichever comes first. Military Service personnel out-processing centers will forward the HTR to the DVA RMC within five business days of receiving it from the MTF. 2. As the last few weeks of service are often characterized by medical testing and follow-up care, the practice of pre-positioning HTRs at Military Service out-processing centers will cease.

13. The Way Ahead 3. Military Service out-processing centers will implement procedures to ensure that records of still-serving members and their dependents will not be transmitted to the DVA, but instead will be incorporated into the HTR of the affected person.

14. The Way Ahead 4. DoD Instruction 6040.43 paragraph 5.1.2.3 requires each Military Department to “establish a policy that ensures ‘no hand carrying’ of medical records by beneficiaries.” These records are the property of the Department and must be transmitted through channels guaranteeing timely receipt by the appropriate federal office. (There are no restrictions on what Service members may do with their own copies of these records.) 5. From this point forward, decedent records (absent conflicting waivers) will be forwarded to the DVA RMC within 30 business days of the death of the Service member. The ASD (HA) will work with the Office of the Armed Forces Medical Examiner to develop a plan to eliminate the back-log of decedent records.

15. The Way Ahead 7. The Services will develop metrics and data collection mechanisms to track our progress reducing the number of incomplete HTRs and loose documentation received by the VA.

16. HIPAA – PHIMT – Disclosures HIPAA – PHIMT – Disclosures Adolescent Records

17. AHLTA Issue: Scanning without indexing . . . Best practice would be: - Scan all network and outside consult reports into the system. - It should be noted that written documentation on the electronic printed SF 600 is strongly discouraged. If this type of documentation and/or pictures, drawings, EKGs etc. exists, they must be scanned in AHLTA so that information is available to all providers and coding personnel. However, many scanned documents will slow down the AHLTA system response time at your facility.

18. AHLTA - MTFs develop local policy to ensure availability of health information when a patient presents for a visit. - MTFs will establish procedures for short term and long term periods of system downtime. - MTFs will have to develop a policy for coding during down times.

19. Paper Record Transition Working Group (PRTWG) • Address issues regarding the development of a strategic management plan for the migration from paper records to the EHR. • Standardize content of the EHR - Guidance for users when AHLTA goes down. - Guidance for what to do when AHLTA data is irrevocably lost. - Scanning solutions.

20. QUESTIONS? Forward questions to: susan.pierce@med.navy.mil (202)762-3162 DSN: 762-3162