During a management meeting, Blair, Steven, and Jarrett discussed a serious problem with the master patient index (MPI) at Aubreyville Regional Hospital. Blair, Aubreyville’s HIM Director told the team that she had noticed a drastic increase in the requests to combine duplicate medical record numbers. Blair’s team is responsible for the actual merging of the duplicate numbers. Typically, HIM identifies the duplicates or another department locates them and contacts the HIM department. Blair had asked her team to keep a count of how many pairs are merged so the data can be trended daily, weekly, monthly, and yearly. After her last audit, Blair created a line graph to show the progress or decline of duplicate medical record number creation.
Steven, Patient Registration and Admitting Director at Aubreyville, worked closely with Blair to ensure he understood which of his team members were inadvertently creating the duplicate numbers during the registration process. Through this work, Steven was able to pinpoint which of his staff members was more error-prone than others. Jarrett, Information Services Director, was also a great resource because he provided reports that were generated out of the hospital information system (HIS).
After discussing the upward trend, the team decided that a root cause analysis should be performed to fully understand the impact of a MPI that contains numerous duplicates. The deep dive into the analysis would be a multi-faceted review that would take place over a week. Jarrett was tasked with generating daily reports to show potential duplicate creation. The report would contain the employee numbers so that Steven could drill down and aggregate the number of duplicates created by each of his registration staff members. If certain staff members continued to create multiple duplicates, Steven would know that additional training was needed. During the review period, Blair would also trend out the number of duplicates cleaned by her team. Through all these efforts, the team could develop training and communication opportunities.
At the end of the review period, the team reviewed the results. They learned that a few registrars were creating nearly all the duplicate errors. Steven determined that those staff members would be retrained and audited on a regular basis. Blair and Jarrett agreed to keep reporting available to provide Steven with information to track improvement. The team was satisfied that they had a good plan to follow going forward.
1. Why did the areas of registration, HIM, and IS all need to provide input to solve the duplicate medical record problem?
2. A few registrars made nearly all the duplicate errors. Why did these registrars need to be retrained?
3. Why do Blair and the HIM team trend out the number of duplicates that they resolve?
SENARIO
The release of information (ROI) function at Delaney Hospital is outsourced to Green Release Company. Green Release Company handles all release of information activities, including providing computer equipment and personnel to track the release of records. The company is a small family-owned business that focuses on high integrity and getting the records released in an expedited manner. Unfortunately, the chart release software used by Green Release Company is quite outdated. The software was created when the company started to provide services. The software has never been replaced because it has always been reliable and met Green Release Company’s needs.
Gina, Quality & Privacy Director at Delaney, recently performed a HIPAA audit on all privacy and security-related processes. One of the key services that Gina reviewed in the HIM department was the release of information function. Gina was satisfied with the audit and found that Green Release Company was compliant in nearly all areas. One concern that Gina discussed with Cesar, HIM Director, involved the software that Green Release was currently using.
Gina explained that the accounting of disclosure requirements was not all being logged appropriately in the system. HIPAA requires all covered entities to establish a tracking mechanism and reporting process that includes the following: date of disclosure, name and address of the entity or person who received the PHI, description of the PHI disclosed, and statement of reason for disclosure.
During her audit, Gina felt that there was no true description of the PHI disclosed being populated in the description section of the software. She felt this could be a risk because the description is not typed out for tracking purposes. Gina proposed to Cesar that a requirement be placed on the description cell so that the person entering the request would not be able to bypass entering the description. This would help ensure that the description is populated correctly on every request. Cesar agreed that this would be an easy fix and that it is much better to be certain the data is required on every request. Cesar agreed to contact his representative at Green to determine next steps to make this system change.
1`. Why does Gina perform regular audits such as the accounting of disclosure review?
2. Green Release Company is an external company providing services. Do you think Delaney Hospital and other hospitals using their services should verify that Green Release Company’s systems and processes follow HIPAA?
3. When Cesar contacts Green Release Company, how do you think he will approach the topic? What can Cesar do if Green Release Company refuses to make the updates to the system?
