Informa(onGovernanceatUWMedicine

APrac(calApproachSallyBeahan,RHIA,MHA

DirectorHIMUWMedicineChris(neTaylor

UWMedicineRecordsOfficerOrHIMAOctober2016

GoalsofSession

•  General concepts •  Information Governance (IG) and the

Electronic Health Record (EHR) •  What’s happening at UW Medicine •  Questions, Answers, Discussion

Concepts•  Informa(onGovernance

–  AHIMAdefini(onaccountabilityframeworktomanageinforma(onthroughoutitslifecycleandtoachieveEnterpriseInforma(onManagement(EIM)

–  SedonaConference®defini(oninterdisciplinaryapproachtomanaginginforma(on that

supportscomplianceandmi(gatesrisk•  Fullunderstandingandpurposes(llbeingdeveloped•  IGcanbeastrategy,aprogram,and/orawaytochange

businessculture•  IGmustinvolvecollabora(vedecisionmakingregarding

theorganiza(on’sinforma(on

Concepts(con(nued)

•  PrinciplesofEIM(IGPHC™andGARP®)– Accountability– Transparency–  Integrity– Protec(on– Compliance– Availability– Reten(on– Disposi(on

Concepts(con(nued)

•  Informa(onLifeCycle-Crea(on-Use-Storage/maintenance-Disposi(on(destroyorpreserve)

•  Informa(onisavailable,readable,accessible,retrievable,etc.,throughoutitslifecycle

Concepts(con(nued)

•  IGdefini(onsummary–  IGcanbeanyorallofthefollowing:

•  Strategic•  Programma(c•  Vehicleformoderniza(on•  Collabora(ve

–  PrinciplesofEIMdefinegoalsofinforma(onlifecyclemanagement

–  IGisdirectlyrelatedtoeffec(veandlegallydefensibleinforma(onlifecyclemanagementandinforma(ondestruc(on

IGandEHR•  LifeCyclemanagement–  Goal:EHRmanagedascoredigitalassetintrustedanddurablerepository

–  EHRLifeCycleStagesforContent:

•  Create:e.g.,dataentry/transcrip(on,cut/paste,dataintegrity,metadatacapture

•  Use:e.g.,pa(entcare,share/exchange,release,discovery,analy(cs,research

•  Store/Maintain:e.g.,accessandretrieve,authen(city,chainofcustody

•  Disposi(on:PreserveorDestroy

Create/Capture

Use/Process

Store/Maintain

Preserve/Destroy

IGandEHR(con(nued)–  EHRLifeCycleStagesforRepository:

•  Create:e.g.,newtechnology,planfields,automateworkflow,loca(onofhost(ownership/control),etc.

•  Use:e.g.,systemupdates,logs,security,etc.•  Store:e.g.,accessibilityoflegacysystems,migra(on(allorsome),etc.

•  Disposi(on:e.g.,doesrepositoryhavelifecyclecapabili(es–automateornot,etc.

•  EHRlifecyclecannotbeeffec(velyorefficientlymanagedinavacuum

•  IGistheframeworkforcollabora(velifecyclemanagementdecisions

IGandEHR(con(nued)

IG

HealthInforma(onManagement

SubjectMaberExpert

Compliance

RiskManagement

Informa(onTechnology

RecordsandInforma(onManagement

IGCollabora(on

RecordCreator

UW Medicine AHIMA IG Pilot Site

•  8En%%es•  UniversityofWashingtonMedicalCenter

•  HarborviewMedicalCenter•  NorthwestHospital•  ValleyMedicalCenter•  UWPhysicians•  UWNeighborhoodClinics•  AirliANorthwest•  UniversityofWashingtonSchoolofMedicine

AHIMAPilotSiteApproach&Goals

•  IGimplementa(onapproachop(ons:– Globalgovernancestructure– Narrowerapproachstar(ngwithHIM

•  UsetheAHIMAIGToolkittoassessthelevelofIGimplementa(onatourorganiza(on

ApplyingIGConceptsinHIM

•  Brainstormedprojectsandac(vi(esthatwereinflight

•  Mappedthoseac(vi(estotheAHIMAIGCompetencies,somerelatedtomul(plecompetencies

•  Ratedthelevelofimplementa(onusingtheIGHealthRateassessmenttool

•  Iden(fiedthenextstepsneededtoadvanceeachac(vityalongtheAHIMAIGlevels

Example#1Ac#vity Competency Principles Ac#on/Goals

Digi(zingmedicalrecords

DataGovernanceEnterpriseInforma(onManagement

Reten(on/Disposi(onIntegrityChainofCustody

Updatereten(onscheduleforscannedrecordsUpdatescan/destroypolicyPolicyapprovalthroughHIMOpera(onsCommibee

Example#2Ac#vity Competency Principles Ac#on/Goals

Legacyinforma(onandsystems

EnterpriseInforma(onManagement

LongTermDigitalPreserva(onTransparencyAccess

InventorylegacysystemsIden(fyreten(onperiodsCreatenewrecordseriesifapplicableDeveloppolicyforaccessoncedeac(vated

Example#3Ac#vity Competency Principles Ac#on/GoalsInforma(onmapping:EHRandsecondaryrecords

DataGovernanceEnterpriseInforma(onManagement

MetadataTransparencyAccess

AssessvalueofdevelopingmappingresourceDevelopmappinginstrumentCollaboratewithITregardingthedevelopmentofmappinginstrument

Example#4Ac#vity Competency Principles Ac#on/GoalsLegalandSecondaryMedicalRecords

StandardOpera(ngProceduresInforma(onLifecycleManagementSecurityandPrivacySafeguardInforma(onTrustworthinessDataGovernance

TransparencyBusinessCon(nuityandDisasterRecoveryReten(on/Disposi(onManagementBusinessCon(nuityDataQualityLongTermDigitalPreserva(on

Updatepoliciesdefiningthelegalmedicalrecordacrossen((es.Updatepoliciesdefiningsecondarymedicalrecordsacrossen((es.SummariesofApplica(oninventoriestobeaddedtoUpdatereten(onschedulesascompletedDevelopLTDPstrategyforEHRandsecondarysystems-collaboratewithSMEsre:plandevelopment

IGCaseStudy

•  Focusonnewpolicycrea(onandcollabora(on–  RevisingtheLegalMedicalRecordpolicyincludingdifferen(a(onoftheDesignatedRecordSet

OutsideDRSandLMR(releasedforlegal/judicialrequests)

· PsychotherapyNotes· LegalWorkProduct· PatientSafety· QualityReview

DesignatedRecordSet(DRS)(releasedforspecificrecordsrequests)

· “Source”SystemContent· DiagnosticImages· BillingInformation· HealthPlanEnrollment· ClaimsAdjudication

LegalMedicalRecord(LMR)Releasedforrequestsformedical

records)· Clinical/DiagnosticReports· Clinical/Diagnosticsummaries· ClinicalNotes· LabSummariesandReports

HealthRecordDataSetsSeptember2016

AHIMAIGToolkit

AHIMAIGToolkit

•  HelpfultoourIGini(a(ves•  Hi-litedIGProgramvsIGStrategicApproachwhichimpactedourscores

•  AHIMALevels3-5inIGHealthratearespecifictoanIGProgram

WhyisIGImportant?

•  RiskReduc(on•  OrganizeInfrastructure•  IncreaseValue•  ProcessImprovements•  BusinessModerniza(on

KevinOgrodnik,Informa(onGovernanceROI,ARMAHotTopics

Ques(ons?

SallyBeahansbeahan@uw.eduChris(neTaylorct24@uw.edu