management, compliance, accreditation and standards, and the offi ce of general counsel.
Three of the functions of the health record executive committee are:
1. Establishing and implementing standards for the health record regardless of the media on which the information is used, collected or stored. 2. Authorizing and approving policies and procedures concerning the health record.
3. Establishing standard documentation practices. One of the fi rst policies developed and approved by the health record executive committee was “Carry forward of clinical information in the EHR.”
Mary G. Reeves, RHIA, is director, medical information services, Vanderbilt University Hospital.
Rita Bowen, M.A., RHIA, CHPS, SSGB, is SVP of HIM and privacy offi cer, HealthPort. For more on HealthPort: www.rsleads.com/206ht-208
Cut and paste (also known as cloning, re-use, carry for- ward) is ubiquitous – espe- cially with electronic docu- mentation. Every electronic record has a large population of cut-and-paste information. And while the cut-and-paste feature benefi ts clinician pro- ductivity, it can create a data
integrity problem for the organization. The feature needs a structural policy that is managed and reviewed. Key points of the policy are: • Carry forward with caution;
• Information that is carried forward is uniquely identi- fi ed; and
• More documentation doesn’t necessarily mean better documentation.
At Vanderbilt, all cut-and-paste information stays a dif- ferent color until it is reviewed and authenticated by the clinician. Vanderbilt also audits clinicians on adherence to the cut-and-paste policy.
In addition to the “carry forward of clinical information”
policy, these policies have been approved: • Defi nition of legal medical record; • Electronic signature; • Additions, corrections and deletions in the electronic medical record;
• Naming convention standards; and • Scanning and indexing standards.
A new role for HIM professionals Vanderbilt learned that data governance is the foundation of the EHR, but many other organizations have not. Health- Port, a leading ROI service provider, confi rms this fact. Both Vanderbilt and HealthPort report that IT system administrators usually become the owner of data. Within each application this makes practical sense. However, data governance must oversee consolidated data from multiple silos, not just one system.
Health information management (HIM) professionals are www.healthmgttech.com Foundation for understanding
Clinical data can be very unstructured and heterogeneous. While this fact may support the originator of the data, it causes problems for other users and the overall organization. For EHR data to become actionable information and used by clinicians in direct patient care, there has to be a high level of trust in the integrity of that information. Data governance helps make electronic information usable and available to caregivers, researchers, quality monitors and future reimbursement modalities. To be of value, the data must be normalized and comparable, as well as consistently defi ned and understood. Data governance is the foundation of that understanding.
Like many other institutional problems, it is important that data governance be encapsulated within visible policies and procedures, and that they remain living, breathing documents – essential ingredients within the institutional culture. HMT
HEALTH MANAGEMENT TECHNOLOGY June 2012 11
well equipped to complement this enterprise-wide focus, as they know how to ensure data integrity, accuracy, complete- ness and privacy of information contained within medical records. HIM professionals are already trained and deep into ROI, privacy and HIPAA, which, as stated, are essential components of data governance. As the siloed data came into their EHR, Vanderbilt learned that information is not the same across departments. HIM is adept at inter-departmental translations and knows how to manage all the various data politics.
A consistent, updated data dictionary is required Organizations should continually review the core policies and procedures driving governance. One major need is a data dictionary. Many do not know what a data dictionary is, or if they do, have not implemented it. Teams should be effective at mapping data and building their data dictionary as the organization implements and transitions between systems. Each data element must be de- fi ned, verifi ed and edited such that it does not lead to wrong information in a patient’s record. Incorrect record data can lead to dramatic adverse events and erode an organization’s valuable patient safety initiatives.
Data governance helps make electronic information usable and available to caregivers, researchers, quality monitors and future reimbursement modalities. To be of value, the data must be normalized and comparable, as well as consistently defi ned and understood. Data governance is the foundation of that understanding.