Functionality: beyond a checklist

Legacy Health System, situated in a rural county, consists of a small short-term acute-care hospital, an urgent care center, a multi-specialty clinic, and an outpatient cancer center. The acute-care facility has a single, integrated EHR system. The multi-specialty clinic uses a clinical system supplied by a different vendor, and the urgent care and cancer center both use different clinical special systems.

Information sharing among the facilities is a challenge since none of the systems are interoperable. Frequently, cancer center patients need to be admitted to the acute-care facility. When this occurs, the physicians use the acute-care system but also continue to use the cancer center computer system to document chemotherapy and related treatments the patient might receive while hospitalized. Thus, documentation during the inpatient visit is contained in two different systems.

To ensure that the hospital has all documentation associated with the inpatient encounter, a decision was made to investigate scanning output from the cancer center system into the electronic document management system that was part of the hospital’s EHR system. In evaluating the electronic document management system, a checklist of functionalities was reviewed by a HIM team. The team learned that the scanned records could be integrated with the inpatient medical record and that other functionalities such as full-text indexing, key work indexing, document indexing, multiple access, and version control could be enabled.

The team wanted to ensure that the electronic document management system included an annotation functionality providing the ability to add or remove information about a scanned record without permanently changing the original image. This feature was important should there be an error in the original record or if the scanned record that was uploaded required redaction. For example, in the case of scanning documents and linking them to the wrong inpatient encounter or patient chart.

While the system included the annotation function, what the team discovered during a process walk-through was that when information was released for insurance and other purposes, all redacted information would be released as well, even in situations where the scanned documents were linked to the wrong patient. In other words, there would be a potential privacy breach if records for Mrs. Smith were released that also included redacted records of another patient.

Discussion Question

The team learned that functionality is more than checking “yes” and “no” boxes on a functionality list. What saved the team from making a serious mistake in selecting the document management system was conducting a process walk-through that evaluated the system through all the stages of the data lifecycle. In actuality, the system did not meet the functionality that Legacy Health System required, even though the function could be checked “yes” on the function checklist.

What type of safeguards should be in place to make sure that system functionality meets the organization needs and compliance requirements?

Should a DG policy be developed and if so what would be the wording of the policy?