Policy And Procedure For Disclosure Management

Policy and procedure for disclosure management and Procedures for MPI (Master Patient Index)

Unfortunately, your team works at a facility which has not yet implemented an EHR. The HIM department is very dependent on various software systems to function. The facility still has paper records, but chart requests, disclosure management, dictation systems, chart locators, MPI and chart deficiencies are all computerized. Create a policy and procedure which outlines how the department would operate if one of these systems went down. You need to create policies and procedures here – one for each system. (Hint: Use a policy and procedure template). Policy and procedure for disclosure management and Procedures for MPI (Master Patient Index)

Paper for Above instruction

Introduction

In a healthcare facility that relies heavily on computerized systems for managing health information, ensuring continuity of operations during system outages is critical. This document delineates policies and procedures for two vital systems within the Health Information Management (HIM) department: Disclosure Management and the Master Patient Index (MPI). These protocols are designed to minimize disruption, maintain compliance, and uphold patient confidentiality when systems experience outages or failures.

Policy for Disclosure Management System

The facility’s Disclosure Management System (DMS) is essential for tracking and managing patient disclosures, ensuring compliance with legal and regulatory requirements. In the event of a system outage, the HIM department shall adhere to the following policy:

• Continued Operation in Paper Format: All disclosure requests received during the outage shall be documented manually, with records maintained securely and accurately.
• Manual Documentation: The HIM staff shall utilize printed or handwritten forms to document disclosures, including patient identifiers, disclosure details, date, and approver signatures.
• Verification and Validation: When the system is restored, manual records shall be reviewed and transcribed into the electronic system, ensuring data integrity and compliance.
• Security and Confidentiality: Manual documentation must be stored securely, following privacy policies, until electronic systems are operational again.
• Communication: All relevant departments shall be notified of system outages and manual procedures, ensuring coordinated response and compliance with legal obligations.

Procedures for Disclosure Management System Outage

1. Notification: Upon identifying a system outage, the HIM supervisor shall notify the IT department immediately and inform all HIM staff about the outage and manual procedures.
2. Manual Record-Keeping: HIM staff shall utilize pre-approved paper forms to document any new disclosure requests, including patient authorization, recipient details, and purpose of disclosure.
3. Workload Management: During the outage, prioritize urgent disclosures and document all activities meticulously.
4. Data Transcription: Once the system is operational, manual records shall be entered into the electronic Disclosure Management system, verifying accuracy and completeness.
5. System Restoration and Audit: After system restoration, the HIM team shall perform audits comparing manual records against electronic logs to ensure all disclosures are accurately captured and documented.
6. Compliance Documentation: Maintain records of manual processes and audits for compliance and potential audits by regulatory agencies.

Policy for Master Patient Index (MPI)

The MPI is the central repository for all patient identifiers and demographic data, critical for accurate record locaton and retrieval. During a system downtime, the following policy shall be observed:

• Manual Record Search: HIM staff shall conduct manual searches for patient records using demographic information in the paper files to locate and verify patient identities.
• Temporary Record-Keeping: When necessary, temporary paper logs shall be maintained to document patient information, search activities, and identified records.
• Data Verification: Pending system restoration, manual records shall be cross-checked against existing paper files to ensure accuracy.
• System Restoration: Once MPI systems are back online, manually recorded searches and updates shall be transcribed into the electronic index.
• Security and Confidentiality: All manual records shall be stored securely, with access limited to authorized personnel, to maintain patient confidentiality.
• Staff Training: HIM staff shall be trained periodically on manual MPI procedures to ensure readiness during outages.

Procedures for MPI System Outage

1. Outbreak Notification: HIM supervisor shall alert the IT department and notify all relevant staff upon detection of an MPI system failure.
2. Manual Lookup Process: Staff shall use demographic data such as patient name, date of birth, and social security number to perform manual searches in paper files or logs.
3. Documentation of Searches: All manual search activities shall be documented in a designated manual log, including date, time, patient identifiers, and search outcome.
4. Temporary Patient Record Creation: If necessary, temporary identifiers may be created with proper tracking, until the MPI is restored.
5. Transcription Post-Restoration: Once the system is operational, manual entries shall be reviewed and transcribed into the electronic MPI, with cross-verification for accuracy.
6. Audit and Compliance: Post-restoration audits shall be conducted to reconcile manual records and ensure data integrity and compliance.

Conclusion

Maintaining the functionality of the HIM department during system outages demands structured policies and procedures that prioritize accuracy, security, and compliance. By establishing clear manual processes for disclosure management and MPI activities, the department can ensure continued access to vital health information, support legal and regulatory compliance, and uphold patient privacy during technological disruptions.

References

• Ambrosino, J. M. (2019). Health Information Management Technology: An Applied Approach. Elsevier.
• HIMSS. (2020). Emergency Preparedness and Business Continuity Planning for Healthcare. Healthcare Information and Management Systems Society.
• American Health Information Management Association (AHIMA). (2018). Standards of Ethical Coding. AHIMA Press.
• McWay, D. C. (2021). Management of Health Information. Springer Publishing Company.
• Jin, J., et al. (2019). Health Data Security and Privacy: Challenges and Solutions. Journal of Medical Systems, 43(9), 234.
• U.S. Department of Health & Human Services. (2022). HIPAA Privacy Rule and Disclosures. HHS.gov.
• Rothstein, M. A. (2017). Protecting Patient Confidentiality in the Digital Age. Journal of Law, Medicine & Ethics, 45(2), 174-182.
• Nelson, R. & Staggers, N. (2018). Health Informatics: An Interprofessional Approach. Elsevier.
• Osborne, N. H. (2020). Business Continuity Planning in Healthcare. Springer.
• Walker, J., et al. (2021). Electronic Health Record Management and System Outages. Journal of Healthcare Information Management, 35(2), 123-129.