Section 4.14 Implement

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.

A small local health facility may not have very many documented policies and procedures, so this can be a good time to review your needs and add needed policies. Although many types of policies and procedures are useful, those directly associated with EHR and privacy and security are required to be documented under HIPAA and their absence could pose a problem if your facility is audited.

Time needed: 12 monthsSuggested 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 documentsElectronic 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

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Application Date Last Revised

Modification?

Date Revised

Use and retention of metadata Managing the data dictionary Change control EHR training compliance Email Client-generated electronic documentation (e.g.,

authorizations, consents, advance directives, self-administered health histories, email, texts, chat)

Managing client access Managing amendments Managing restrictions, including those to health

plans where payment in full has been made for service

Accounting for disclosuresSecurity 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 notificationInteroperability 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, RxNorm, DSM-5) 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 other providers Interoperability with Public Health (e.g.,

immunizations, reportable lab results) Electronic submission of quality measurement data Electronic submission of data for state reporting Medical device connectivityPersonal Health Record Personal health record

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

Application Date Last Revised

Modification?

Date Revised

Consent management Education and instructionsHealth Information Exchange Global person identification Record location Data sharing agreement Participation agreement Consent managementOther (Specify…)Copyright © 2014, Margret\A Consulting, LLC. Used with permission of author.

Copyright © 2014 Stratis Health. Updated 03-13-14

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