Unit 3 – Medical Records, Electronic Medical Records, and Health Information Technology

Unit 3 – Medical Records, Electronic Medical Records, and Health Information Technology

Part 1: Medical Records Policy Update Regional Hospital

Our policies must be up-to-date with the most recent legal, ethical, and operational best practices in order to provide safe, high-quality treatment in an industry that is always changing due to the introduction of new technology and patient interaction models. Our medical records policy has been updated to cover important topics such as ownership, release/consent, retention, modification, storage, destruction, and the implications of health information technology (HIT). We have also taken into account relevant legislative issues, such as social media and telemedicine, which are becoming more influential in healthcare delivery. By updating these standards, we may improve our future preparedness and provide the groundwork for therapeutic choices based on compliant, patient-centered record-keeping.

Records Ownership

At this time, our medical records policy states that any documentation generated by our hired doctors or external partners treating patients inside our care environments remains the legal property of the organization. Nevertheless, contemporary viewpoints acknowledge that this does not promote patient agency and sidesteps the ethical duty as guardians to responsibly handle protected health information on the patient’s behalf for the only purpose of aiding treatment, not asset control. Legally the records belong to the practice; but ethically, patients have ownership rights over health history contents that should enable access, sharing limitations, and expect fiduciary responsibility from providers entrusted as custodians without personal gain motives beyond reimbursement tied directly to treatment expenses (HealthIT.gov, 2021).

Therefore, the updated policy will clarify that we serve as custodians managing patient records to support confidential care delivery, absent personal ownership assumptions. We must allow patient involvement in release decisions and access processes subject to ethical parameters. This balances legal compliance with nurturing patient trust and engagement in their care through transparency. To implement this shift, patient portals and personal health record functionalities will expand while streamlining medical release form workflows focusing on custodian delineations and the explication of specific access levels or permission constraints at the patient’s discretion.

Record Release and Patient Consent

The current policy only states that patients must sign a release form that generally allows informational disclosures in order to authorize the sharing of their data with other parties. Nevertheless, there is a lack of subtlety in this procedure when it comes to varying degrees of approval. For instance, patients could want only certain people to see their surgical reports while others only see their mental health notes. The implementation of granular consent requirements is mandated under the Health Insurance Portability and Accountability Act (HIPAA) (U.S. Department of Health & Human Services, 2022).

To further accommodate patients’ needs for information sharing beyond the scope of their initial treatment, the updated policy will include a tiered permission system. Differentiated approaches cover topics like limiting the types of records shared (e.g., just recent hospitalization records vs. full history since birth), identifying which providers receive the records (e.g., local hospital vs. specific surgeon), and temporally constraining the access date range versus open-ended placement. Some categories are entirely excluded, such as psychotherapy visit details. These tiers may be more easily indicated using checkboxes on the release form. While written signatures are still required for higher-threat permissions, verbal approvals accompanied by identification verification might be used to include lower-risk permits in the medical record. In order to avoid any potential exposure or inappropriate disclosures, it is imperative that all organizations and practices that get access to medical records adhere to strict confidentiality and security measures that mirror our internal regulations. Formal data-sharing agreements and authorizations from permission forms will be used to contractually enforce this.

Record Retention

Federal and state deadline minimums for adult patient data spanning ten years from the most recent healthcare visit are satisfied by our existing retention term (AHIMA, 2022). On the other hand, public health researchers should keep tabs on epidemiological trends over several decades by keeping full histories beyond this time frame; this will help with patient safety, prevent unnecessary testing, speed up decision-making in critical situations, and more (OCIO, 2020).

Hence, the revised policy will extend the time records that are kept for adults to 20 years, and for children, they will be kept until they are 55 years old or until 20 years have passed since they became adults. In the long run, this improves diagnosis accuracy and care coordination by giving patients more time to ask for personal copies of their data. In addition, it satisfies the growing number of payer contract needs for analytics report disclosures, monitoring results, and usage indicators across larger member risk pools over longer periods. To safeguard kids from possible lawsuits when they attain legal age and begin to question their childhood care experiences, it is recommended that their records be kept for at least a few decades after pediatric treatment has ended. We shall ensure that all written or printed records are stored in safe, environmentally controlled facilities on-site. Every year, in order to create room for more recent material, the HIM team will methodically move eligible records to commercial offsite medical storage suppliers as they approach but are still within the minimal retention limits. Encrypted cloud storage meets the need for both security and retention of digital and scanned information.

Record Modification

Current policies lack clarity regarding procedures for updating documentation after the initial clinician signature denoting care episode completion. However, errors found subsequently or record consolidations from external organizations with conflicting details occasionally warrant modification. The drafted HIPAA “right to amend” proposal affirms patient rights, requesting amendments to perceived erroneous/incomplete health records (U.S. Department of Health & Human Services, 2022).

As such, the revised policy will map workflows, designating the HIM team as the hub managing incoming amendment requests, whether from patients directly or from internal staff, and identifying documentation discrepancies. They will oversee validating errors/omissions, ensuring revised accuracy, recording authorization for changes, facilitating system updates both within electronic health records (EHR) and existing paper archives, and communicating completion to all involved. We will append versus overwrite original entries to maintain evidence trails reflecting care delivered initially before correction. Approved changes will denote the amending party, timestamp, and reason alongside the original text marked erroneous. If disputes about amendment justification arise that cannot be resolved through open dialogue and investigation, patients can submit formal statements of disagreement for appending to contested record sections. However, modifying documentation absent permissible rationale remains ethically and legally prohibited.

Record Storage

Our health system currently relies heavily on scanned paper record archives with digital copies stored locally onsite and backed up to tapes kept in offsite facilities. A data center houses our EHR infrastructure with enterprise storage equipment. While these achieve baseline security and access expectations, rapidly evolving interoperability needs and telehealth service expansions necessitate adopting newer modalities. As such, the revised policy will pursue hybrid cloud storage integrating local servers, private cloud platforms, and public cloud repositories to balance security, scalability, functionality, and costs dynamically (Mehrtak et al., 2021). This facilitates easier record consolidation with our pedigree/enterprise master patient index (EMPI) mapping patient data linkages across various electronic systems, care venues, and partnerships. Using the cloud also future-proofs storage capacity constraints while enhancing resilience and data recovery from potential disasters/outages through geographic distribution (Gupta et al., 2022). Strict access controls for segmented networks will maintain confidentiality. The hybrid model prevents full reliance on third-party vendors. Modern encryption applied before uploading to the public cloud safeguards from hacking risks. As we retire legacy paper archives, digital scanning facilitates shredding disposition per destruction workflows. But moving forward most documentation will natively begin in structured EHR formats simplifying system consolidation and analytics integration.

Record Destruction

Currently, our policy simply states medical records are no longer subject to retention schedules and undergo incineration by authorized waste management contractors. However, environmental considerations make this approach unsustainable for a long time. Further, increased digital documentation warrants safe electronic record deletion protocols before discarding retired scanning/storage hardware itself through site wiping, physical destruction, and recycling (Gupta et al., 2022).

Therefore, the revised policy will implement formal record inventory reviews intermittently against defined retention schedules to earmark particular record sets for archive conclusion subject to final HIM approval, verifying no disputes/exceptions. For paper records, high-volume commercial cross-shredding will replace incineration moving forward as it facilitates the recycling of the resultant fibers. Strict chain of custody controls will apply during transport from our facilities to shredding plants. Meanwhile, the HIM team will electronically delete identified digital archives per application and operating system guidelines before wiping retired servers/devices (Gupta et al., 2022). Both digital and paper destruction workflows will have documented verification.

Part 2: Health Information Technology, Legislation, Social Media, and Telemedicine

While our policy updates have incorporated some relevant HIT expansions thus far, assessing additional considerations is prudent given the fast evolution. First, interoperability milestones demand structured documentation practices and common terminologies to exchange computable data discretely across a variety of platforms – whether for public health reporting, care coordination transitions, clinical research, or patient access exchanges. Adopting next-generation EHR systems accelerates real-time interoperability through API integrations. Enhanced patient portal tethering also fosters engagement.

Second, when combined with various digital data sets, fast-growing decision-support systems such as AI have enormous promise for improving clinical workflows, accurate diagnosis, treatment planning, operational efficiency, and predictive analytics (Gerke et al., 2020). However, developers must curate record access carefully to advance functionality safely first.

Third, as telehealth adoption grows under expanded payer policies, integrations between virtual platforms and provider EHR environments must strengthen to prevent data fragmentation through video visits untethered from member medical history (Kichloo et al., 2020). Policy standards are still lacking industrywide. Therefore, we must strategically partner to guide expectations.

Lastly, patient-centered interoperability offers therapeutic benefits by facilitating the sharing of health information across previously isolated platforms. However, it also raises the danger of cyber exposure in the absence of adequate access controls and security frameworks (Torab-Miandoab et al., 2023). Testing for vulnerabilities is crucial. Consequently, our health system will not lag behind rivals that are rushing to implement cutting-edge technologies without proper protections, thanks to our relationship with HIT suppliers, which promises to tread gently but steadily on new frontiers. Prioritizing investments takes community expectations into account.

Key Legislative Considerations

The dynamics of medical records are addressed in a number of healthcare regulations that have been enacted in the previous ten years. According to the U.S. Government Accountability Office (2013), the HITECH Act enhanced privacy and security enforcement, strengthened business associate agreements for third-party record sharing, increased adoption of electronic health records, and established the Office of the National Coordinator for Health Information Technology (ONC) to oversee health information technology. The ACA forbade record discrimination based on preexisting illnesses and required health information exchanges to centralize public health and improve reporting efficiency. To ensure that patients may access their information without any hitches across many portals or applications acting as data holders rather than isolated source copies, the 21st Century Cures Act pushed for the establishment of interoperability standards. When no policy violation or patient safety risk exists to warrant constraint, organizations cannot delay records release arbitrarily, which limits care coordination for transitions, concurrent treatment, or patient wants, according to the new information-blocking regulations (HealthIT.gov, 2022). By keeping an eye on this historic legislation while implementation rules are being crafted, we can ensure that our medical records policies align with the federal policy goals that prioritize security, interoperability, and patient control.

Social Media & Telemedicine Impacts

Platforms provide communication routes addressing patient groups directly, even if there are no explicit intersections between social media and medical records administration. Even if there is no official documentation requirement for comments or advice, our providers are expected to maintain professional standards online. According to Zhang et al. (2023), content has the potential to perpetuate public misunderstandings that might be addressed by more conventional means. This exemplifies a focus on staff education.

The growing use of telemedicine for video visits does, however, have far-reaching consequences for medical records, as these virtual meetings between patients and providers are becoming more common. In order to avoid issues like incorrect coding or missing records, platform connections with electronic health record documentation tools and practice management billing standards need to be reliable (Solimini et al., 2021). Afterward, closed captioning may be integrated straight into structured record fields if visit sessions are recorded. It is essential to ensure that telehealth partners have access to patient portals and follow consent requirements when hosting virtual encounters. Consequently, taking into account the projected expansion of the sector, it is crucial to prioritize the necessary documentation, privacy/security, and reimbursement compliance in telemedicine, even if social media may not significantly affect policy (Kichloo et al., 2020).

Conclusion

Healthcare companies must prioritize modernizing medical record policy components in order to continuously give good care. The precise standards that protect security basics and patient rights nurture everything else conceivable in health system operations and community wellness, even if records represent clinical support that gets low public awareness. The hospital’s continued success through technological shifts and care delivery innovations will be supported by an ethical, legal, and operational framework that includes revised ownership transparency, release specificity through differentiated tiers, updated storage modalities, updated retention justification, modification accountability, awareness of environmental destruction, scaling interoperability, tracking legislation, social media sensitivity, and telehealth accountability. The foundation will keep patient welfare at the center. In line with our purpose, the implementation of this revised policy is expected to enhance quality, safety, satisfaction, and community trust.

References

AHIMA. (2022). Health Information 101. AHIMA. https://www.ahima.org/certification-careers/certifications-overview/career-tools/career-pages/health-information-101/

Gerke, S., Minssen, T., & Cohen, G. (2020). Ethical and Legal Challenges of Artificial Intelligence-driven Healthcare. Artificial Intelligence in Healthcare, 1(1), 295–336. https://doi.org/10.1016/B978-0-12-818438-7.00012-5

Gupta, S., Modgil, S., Kumar, A., Sivarajah, U., & Irani, Z. (2022). Artificial intelligence and cloud-based Collaborative Platforms for Managing Disaster, extreme weather, and emergency operations. International Journal of Production Economics, 254, 108642. https://doi.org/10.1016/j.ijpe.2022.108642

HealthIT.gov. (2021). National Trends in Hospital and Physician Adoption of Electronic Health Records | HealthIT.gov. Www.healthit.gov. https://www.healthit.gov/data/quickstats/national-trends-hospital-and-physician-adoption-electronic-health-records

HealthIT.gov. (2022). Information Blocking | HealthIT.gov. Www.healthit.gov. https://www.healthit.gov/topic/information-blocking

Kichloo, A., Albosta, M., Dettloff, K., Wani, F., El-Amir, Z., Singh, J., Aljadah, M., Chakinala, R. C., Kanugula, A. K., Solanki, S., & Chugh, S. (2020). Telemedicine, the current COVID-19 pandemic, and the future: A narrative review and perspectives moving forward in the USA. Family Medicine and Community Health, 8(3), 1–9. https://doi.org/10.1136/fmch-2020-000530

Mehrtak, M., SeyedAlinaghi, S., MohsseniPour, M., Noori, T., Karimi, A., Shamsabadi, A., Heydari, M., Barzegary, A., Mirzapour, P., Soleymanzadeh, M., Vahedi, F., Mehraeen, E., & Dadras, O. (2021). Security challenges and solutions using healthcare cloud computing. Journal of Medicine and Life, 14(4), 448–461. https://doi.org/10.25122/jml-2021-0100

OCIO, O. of the C. I. O. (2020, August 18). HHS Policy for Records Management. HHS.gov. https://www.hhs.gov/web/governance/digital-strategy/it-policy-archive/hhs-ocio-policy-for-records-management.html

Solimini, R., Busardò, F. P., Gibelli, F., Sirignano, A., & Ricci, G. (2021). Ethical and Legal Challenges of Telemedicine in the Era of the COVID-19 Pandemic. Medicina, 57(12), 1314. https://doi.org/10.3390/medicina57121314

Torab-Miandoab, A., Samad-Soltani, T., Jodati, A., & Rezaei-Hachesu, P. (2023). Interoperability of heterogeneous health information systems: a systematic literature review. BMC Medical Informatics and Decision Making, 23(1). https://doi.org/10.1186/s12911-023-02115-5

1. S. Government Accountability Office. (2013). Department of Health and Human Services, Office of the Secretary: Modifications to the HIPAA Privacy, Security, Enforcement, and Breach Notification Rules Under the Health Information Technology for Economic and Clinical Health Act and the Genetic Information Nondiscrimination Act; Other Modifications to the HIPAA Rules | U.S. GAO. Www.gao.gov. https://www.gao.gov/products/gao-13-341r#:~:text=The%20final%20rule%20was%20issued%20to%20modify%20the%20Health%20Insurance

U.S. Department of Health & Human Services. (2022, March 31). The HIPAA Privacy Rule. HHS.gov. https://www.hhs.gov/hipaa/for-professionals/privacy/index.html

Zhang, L., Piper Liping Liu, Zhao, X., & Song Harris Ao. (2023). Social media and partnership jointly alleviate caregivers’ psychological distress: exploring the effects of online and offline connectedness. BMC Psychology, 11(1). https://doi.org/10.1186/s40359-023-01415-9

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Assignment Details

For the next 5 weeks, you will have a project that will begin in Unit 1, continuing through all units, and ending in Unit 5. Your discussion and project will be connected each week, so you must complete your discussion work on time.

Unit	Topic
Unit 1	Laws, ethics, accreditation, and moral values
Unit 2	Basis of laws, courts, and contracts
Unit 3	Medical records, electronic medical records, and health information technology
Unit 4	Fraud, abuse, security, and confidentiality
Unit 5	Workplace legalities, discrimination, OSHA, CDC, and CLIA

As Director of Risk Management, you ask the Director of Medical Records about AIU Regional Hospital’s policies on the proper maintenance of medical records. You both decided that the current medical record policy is outdated and needs revision.

Your hospital’s medical record policy needs to be updated to include the following topics:

• Record ownership
• Record release and patient consent
• Record retention
• Record Modification
• Record Storage
• Record Destruction
• Evaluate the use of health information technology (HIT) and legislation on social media and telemedicine in healthcare

Deliverable Requirements: The update to the medical record policy is a two-part project.

Part 1 is policy and procedure related to proper medical record management, and Part 2 evaluates HIT, legislation, and the use the social media and telemedicine in health care. Prepare the medical record policy with at least 5 pages written in APA with 5 sources using APA formatting. Title and references pages do not count as part of the 5 pages.

Submitting your assignment in APA format means, at a minimum, you will need the following:

• Title page: Remember the running head. The title should be in all capitals.
• Length: 5 pages minimum
• Body: This begins on the page following the title page and must be double-spaced (be careful not to triple- or quadruple-space between paragraphs). The typeface should be 12-pt. Times Roman or 12-pt. Courier in regular black type. Do not use color, bold type, or italics, except as required for APA-level headings and references. The deliverable length of the body of your paper for this assignment is 5 pages. In-body academic citations to support your decisions and analysis are required. A variety of academic sources is encouraged.
• Reference page: References that align with your in-body academic sources are listed on the final page of your paper. The references must be in APA format using appropriate spacing, hanging indent, italics, and uppercase and lowercase usage as appropriate for the type of resource used. Remember, the Reference page is not a bibliography but a further listing of the abbreviated in-body citations used in the paper. Every referenced item must have a corresponding in-body citation.