4 EHR and HIE Policies and Procedures Checklist

Section 4.13 Implement

Section 4 Implement—EHR and HIE Policies and Procedures Checklist - 1

EHR and HIE Policies and Procedures Checklist

As you implement an electronic health record (EHR), health information exchange (HIE) service, or other health information technology (HIT), many existing policies and procedures will probably need review and modification. New policies and procedures may need to be created.

Time needed: 12 hours
Suggested other tools: NA

How to Use

Use this checklist to evaluate policies and procedures you may need to add or modify as you implement various applications.

Application / Date Last Revised / Modification? / Date Revised /
Electronic Document Management System (EDMS)
· Managing the hybrid record
· Turnaround time for scanning paper documents
· Electronic signature authentication
· Correcting electronic documents
Electronic Health Record (EHR)
· Applying user preferences to dashboards, task managers, etc.
· Adherence to structured and standardized documentation and workflows
· Acceptable abbreviations for narrative documentation/comment fields
· Bring your own device
· Printing and storing data on a USB drive or CD from the EHR
· Report writing
· Documentation of overriding clinical decision support alerts and reminders
· Managing changes in clinical decision support alerts and reminders
· Keeping clinical decision support current
· Adherence to clinical guidelines and protocols
· Correcting electronic documentation
· Definitions of medication errors
· Data quality and data stewardship
· Documentation improvement
· Definition of legal health record
· Use and retention of metadata
· Managing the data dictionary
· Change control
· EHR training compliance
· Email in EHR
· Client-generated electronic documentation (e.g., authorizations, consents, advance directives, self-administered health histories)
· Managing client access
· Managing amendments
· Managing restrictions, including those to health plans where payment in full has been made for service
· Accounting for disclosures
Security
· Access authorization, establishment, modification, and termination
· Unique user identification and authentication
· Access and audit controls
· Encryption of data on devices, in databases, during transmission
· Facility security controls
· Record retention (paper and electronic)
· Record destruction (paper and electronic)
· Media and device destruction
· Equipment rotation/obsolescence
· Data back up
· Disaster recovery
· Contingency planning
· Incident reporting and response
· Sanction policy
· Remote access
· Acceptable use of Internet
· Breach notification
Interoperability
· Adoption of HIPAA transaction standards and operating rules
· Adoption of technical standards for EHR and HIE (e.g., HL7)
· Adoption of terminology standards (e.g., ICD, SNOMED, LOINC, Omaha System)
· Use of the Consolidated-Clinical Document Architecture (C-CDA), Continuity of Care Document (CCD), and Continuity of Care Record (CCR) for summary of care record exchange and transitions of care information sharing
· Interoperability with hospital
· Interoperability with other providers
· Interoperability with Public Health (e.g., immunizations, reportable lab results)
· Electronic submission of quality measurement data
· Electronic submission of medical documentation for RAC audits
· Medical device connectivity
Personal Health Record
· Personal health record
· Consent management
· Education and instructions
Health Information Exchange
· Global person identification
· Record location
· Data sharing agreement
· Participation agreement
· Consent management
Other (Specify…)
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