Keeping Control

Vol. 18 •Issue 17 • Page 16
Keeping Control

Finding your balance in a hybrid record environment can be tricky.

A study published recently in Perspectives in Health Information Management examined acute-care general hospitals and found that 96.5 percent are either using solely paper or, more likely, working in a hybrid records environment. The study concluded that “As health records continue to migrate toward electronic media, the hybrid record remains a formidable presence and is likely to continue for the foreseeable future.”

This “formidable presence” brings with it myriad challenges. Questions abound about working in a hybrid record environment. Barbara Demster, MS, RHIA, CHCQM, senior consultant with Just Associates, described it as a collective HIM hunger for information, with HIM staffs seeking guidance on how to work in a hybrid environment. HIM directors question how to manage the hybrid record, what needs to be done, how to process workflow, what’s the best way to do things and if there is some sort of magic formula to follow in the hybrid state, Demster explained. “It’s a knotty business flow to implement,” she noted.

ADVANCE interviewed experts in the industry and looked at a few of the challenges that come with implementing and working in a hybrid record environment. A lack of knowledge, preparation and organization often lies at the heart of the problems that arise in the hybrid state. The challenges must be overcome—the hybrid record environment isn’t going anywhere, and HIM directors need to be prepared to meet the challenges head on.

Challenge One: An Inefficient Way of Doing Things

Kelly McLendon, RHIA, president and founder, Health Information Xperts, Titusville, FL, calls himself “a staunch opponent of hybrid records.” It’s easy to see why. Electronic record systems tend to be built by people who don’t understand the inner workings of HIM departments, McLendon explained, and oftentimes, working in a hybrid state is an executive decision and not the choice of the HIM department. “Typically, they’re forced into a hybrid state by administration or some powers that be that think it’s a good idea, who clearly don’t understand record management in HIM,” McLendon said.

McLendon urged HIM directors to push back when management suggests moving to a hybrid record state. Let the higher ups know the full implication of going to a hybrid record, he said, and the HIM director can help define for management what going to a hybrid record will really mean. Usually, it means that the HIM department will be working inefficiently, as the staff members will have to navigate across different systems and change workflow processes.

Hybrid records are far from an ideal state for HIM departments, but with some careful management, HIM directors can work around the inefficiencies. It comes down to careful training, quality improvement measures and having the ability to control the flow of information throughout multiple record-keeping systems, such as paper and microfilm. If you must move to a hybrid record, plan ahead. “You just put the best processes you can in place to manage it,” McLendon explained. “It’s not easy, but if you put your head down and work at it, you can do it.”

Challenge Two: Don’t Get Duped

Besides inefficiency, another issue that tends to crop up as soon as physicians get their hands on an interface is duplicate records. While the duplicate records may have been there all along, the moment the physicians have access to the system and begin to notice duplicate records is the time when they’re most often addressed by an organization, according to Beth Haenke Just, MBA, RHIA, president and CEO, Just Associates. When an organization begins to adopt HIT, Just said, duplicate records tend to bubble to the surface. “The physician is aware that the error has happened, so they tend to put pressure then on the executives of the organization,” Just added, and that’s when HIM is called on to try to fix any duplicate issues.

There’s nary an organization out there without some type of duplicate records problem, Just said, and she recommends that every hospital organization have someone on staff specifically charged with managing the master patient index (MPI). “That is the core table of their entire electronic medical record, and if you don’t get that right, you don’t get anything right,” Just said. “It’s something that has become more recognized as one of the fundamental things you’ve got to get right. Otherwise, your EMR will either fail—and I’ve seen it actually fail in organizations—or there’s tremendous cost on the backend.”

If the MPI can’t be cleaned up before the move to hybrid, often the duplicate records can snowball. Working in a hybrid environment means that information may be scattered across systems, and duplicate records may become repopulated in the main registration databases if the problem isn’t solved. Just doubts that even half of the organizations nationwide have a good, solid quality assurance process when it comes to scheduling and registration, and when it comes to duplicate records, they often originate there. She suggested having centralized management of scheduling and registration staff, and if that’s not a possibility, at least have centralized policies on naming conventions and search routines.

Challenge Three: Keeping Up With Compliance

With duplicate records, it’s important to know all the nuances of your department’s record-keeping system, and the same is true when it comes to remaining compliant with privacy and security laws when working in a hybrid environment. Demster, who is immediate past-chair of the Privacy and Security Steering Committee with the Health Information Management and Systems Society (HIMSS), noted that monitoring access to records can be easier in an electronic environment, and technology can help enforce access rules, depending on the electronic system. However, a hybrid environment means that paper is still in the mix. “In a paper environment, you have to depend on people’s behaviors to enforce access, and that’s just not as hard and fast to do,” Demster explained.

It seem obvious that you must focus on enforcing compliance in the electronic record when you’re getting ready to go to the hybrid state, but if you are still working with some paper, don’t forget that compliance must cover the paper records, as well. Draft appropriate policies and know where all of your data are kept. “Don’t limit yourself to one focus of electronic data,” Demster said.

When working across several systems, also keep in mind that planning is key when it comes to compliance. Demster goes into some organizations and is amazed at how organized and put together everything is when the organization is moving toward an electronic record. Other organizations, however, are not as well prepared, and may not be really focused on the compliance issues. “If you don’t have top management who wants to enforce the issues, then people aren’t going to function in a manner that would enforce privacy and security of information,” Demster said.

Challenge Four: Defining the Legal Health Record

While privacy and security are frequently a focus when moving to a hybrid record state, not enough emphasis is put on defining the legal health record, according to McLendon. Varying degrees of record management capabilities exist for each system within the hybrid record, and every electronic system is different from every other electronic system, he noted. “No two are the same, yet you’re trying to bring it all together and make one record that you’re going to go to court with,” McLendon said. “From a legal health perspective, I think hybrid records are very troubling.”

One problem that arises with defining and managing the legal health record comes because electronic systems are typically designed with physicians in mind—and the systems rarely excel at actually managing medical records, McLendon explained. At one site McLendon visited, if an HIM clerk prints off a copy of the record from the organization’s hybrid system one day, and then a week later another HIM clerk prints off a record for the same request, they may print two different records. “They may actually not print the same documents, because the record-keeping processes of that electronic system are very poor, and it’s hard for the clerks to understand which documents are included in which encounters,” McLendon elaborated. “Therefore, they print different copies off, and they could end up giving the same lawyer two different copies of the medical record, and as you can understand, that’s a huge problem—and that’s typical.”

Proper training and follow-up can help prevent issues like that. “You’ve just got to evaluate your processes and what’s going on. You’ve got to do quality checks,” McLendon said.

Stay in Control

Everyone interviewed stressed that preparation is tantamount to hybrid record success. McLendon encouraged HIM directors to visit the HL-7 Web site and look up the functional profile of legal health records. There, you can view the different functionalities that impact the legal health record. “What I think is when people go to hybrids, they don’t necessarily take a list like that and go look at the different hybrid systems and match them and try to understand the variations in the systems so they can make their record management policies reflect the differences in the systems,” McLendon said. “They’re just not organized enough.”

Demster stressed organization as well. Hybrid records certainly aren’t all alike, and there’s no one-size-fits-all solution to the challenges of working in or moving to a hybrid record. n


Rinehart-Thompson, Laurie A. “Storage Media Profiles and Health Record Retention Practice Patterns in Acute Care Hospitals.” Perspectives in Health Information Management 2008, 5:9 (June 16, 2008)

HL-7. “Legal Health Record System Functional Profile.” Accessed Aug. 4, 2008.

Lynn Jusinski is an associate editor with ADVANCE.