Scenario: You are the HIM Director at Sacred Heart Hospital. An audit was done to ensure all systems are included in the DRS and LHR policies and procedures in preparation for an accreditation site visit. The audit revealed several missing applications. You have already created a list of the missing applications with a brief description of each (listed below). Now, you need to determine if the system information is designated as part of the Legal Health Record or the Designated Record Set (they can be one, both, or neither).
DRS and LHR Classification Directions:
Download the template Download templateand fill in your answers directly in the matrix. You will use the application information listed at the bottom of the page to complete the matrix. Submit your completed matrix as a pdf.
For the first three rows (Application Name, Type of system, Description of Data/Documents), you may copy and paste the information listed below for each application. For the fourth row, you must determine whether the application stores any PHI. For the final two rows, you will indicate whether the documents/information are considered part of the DRS and/or LHR.
Use your judgment to determine which systems would be designated for routine disclosure. Remember that all these systems may be ‘discovered’ (or become part of eDiscovery) during litigation, but only specific ones are typically copied for record requests are made, since the others feed into them on a regular basis.
If the system stores some records and sends others to the EHR, they may be designated as ‘Legal Health Records Defined for Disclosure,’ if they may be routinely requested for subpoenas, legal record requests, and other types of requests. For example, diagnostic images and reports originate from the ImagePACS application. This application stores the actual diagnostic images but routinely sends the reports to the EHR Epictech. The diagnostic images might be a part of the LHR defined for disclosure, but the corresponding diagnostic imaging report may not be as it is routinely sent to the EHR, whereas the images themselves are not.
Epictech (Hospital EHR) – Contains patient summaries, computerized physician order entry (CPOE), nursing documentation and graphics, physician progress notes, transcribed documents, lab results, and diagnostic imaging report documents.
Voicescription (Transcription system) – Temporarily stores audio files and transcribed documents prior to transmission into the EHR.
Chemlab (Laboratory information system) – Originates, but does not store, chemistry and C&S results. Also stores quality control data.
ImagePACS (Diagnostic imaging) – Originates diagnostic images and reports. The reports are sent to the EHR, but the diagnostic images stored in the system.
Business OfficeMax (Billing and financial system) – Used to create, manage, and store patient bills and insurance claims.
Accountminder (Billing and financial system) – Contains general ledger worksheets for back office functions.
PortalView (Patient portal) – Contains information captured from the EHR and Business OfficeMax systems, including patient summaries, discharge instructions, and bills. No patient input is allowed. No information is created within this system; it is simply for patient reference purposes. Any updates to this system must come directly from the EHR and billing systems. Therefore, those systems would be updated first, and then the information would interface automatically into PortalView.
VentCom (Ventilator device) – Stores patient information only while the patient uses it, with limited information sent to the EHR. Once device is disconnected from the patient, the data is erased. No patient data is kept on this device.
EDTech (Emergency department EHR) – ED record creation and management. If the patient is admitted, the patient information is transferred to the EHR system; if not, the information stays within the EDTech system.
Reg-Sched (Patient registration and scheduling system) – Creates patient demographic information within a MPI upon patient registration and scheduling. The information is then interfaced with EHR and billing systems. This is the primary point of creation and management of patient identification information.
