VistA Imaging Policy & Procedures HIM & VistA Imaging Working Together Session 245

1. VistA Imaging Policy & Procedures HIM & VistA Imaging Working TogetherSession 245 Renee George, RN, NTEO Pamela Heller, RHIA, CCS-P Garrett Kirin

2. Table of Contents • Objectives • VHA Handbook 1907.01 • Websites • Scanning FAQ • Policy and Procedure • Quality Assurance and Auditing • Report Types • Errors and Deletions • Configurations • Patch Releases • Q&A

3. Objectives • Session will cover • Policies and procedures related to document capture • Destruction of paper documents • Index terms for images & documents • Patch releases

4. VHA Handbook 1907.01 • Dated August 25, 2006 • Scanned wet-signed documents linked to TIU documents • Documents that cannot be created in or interfaced with CPRS will be scanned • Document imaging process • Upcoming pen & ink changes

5. Collaboration • VHA VI Change Control Board • VHA VI Index Term Review Board • Directives/Handbook • Policies and Procedures • FAQ • New Service Requests • Patch Releases and Training

6. VHA Handbook 1907.01 • External Source Documents • Authenticated documents • Practitioner indicate documents to be retained • Summary progress note • Part of health record once scanned/filed • Request to amend to original source

7. Scanning Requirements • 75 year retention requirement • Minimum scanning resolution • 300x300 dot per inch • Destruction of source documents • Source document is indexed • Imaged as an exact replica of the original document • Quality control processes are in place • Assurance that the imaged document is stored, accessible and retained according to the 75 year retention requirement

8. Scanning Requirements • Is Printing & Filing Necessary • Electronic and digitized records can be efficiently identified for authorized uses • Images are retrievable and legible • Integrity of digitized records is maintained

9. Websites • HIM Document Scanning Page http://vaww.vhaco.va.gov/him/docscanning.html • Scanning FAQ • VHA Handbook 1907.01 • Position descriptions • Standards and competencies • Policies and procedures • Links: VistA Imaging and VI Term Tracker

10. Scanning FAQ • Distributed June2008 • Administrative Documents • Link to Patient Only • Viewable in VistA Imaging with MAGDISP admin key

11. Scanning FAQ • 100% Quality Review • Initial Implementation • Random QA sampling • Fee Basis • Bills • Index to Fee • Closed File Room • Transferring records? • Available electronically in VistA Web/Remote Data View/Remote Image View

12. Scanning FAQ • Blank Pages • Any mark, graphic, character? • Scanner set up • Means Tests • Prior to 1/1/07 • Service Connected

13. Scanning FAQ • Release of Information • Print and certify remote EHR • Alter size of resolution • Digital Images • Identification on Digital Pictures • Close-up digital pictures • Laboratory slide • Image taken by Patient

14. SSN • Corrections • Consent attached to wrong patient • Image scanned on wrong patient • Scanned document with wrong SSN • Handbook 1907.01 pen & ink change • Specify last four of SSN

15. Image Dates • VI can store 3 dates related to an image • Image Capture Date • Stored in VI database • Computed by software • Document Date • Date/Time of creation of original document/image • Created by Patch 59 • Event Date • Date is filed automatically • Not editable by user

16. Goals Do you have a Policy and Procedure for VI Capture that everyone knows about and everyone is following? Is Quality Assurance part of the capture process? Is auditing part of the capture process? Are providers reporting difficulty with using VI Display because patients’ have too much information and they can’t find what they need?

17. Policy and Procedure • Is the policy clearly stated so that everyone understands what can and can’t be captured? • Does the policy speak to scanned documents, or does it include image capture and image imports from CDs? What do you do with a large volume record? • Does your policy outline specifics?

18. Scanning Outside Health Records

19. Quality Assurance • Quality Assurance Process in VI Capture • Follow the site Policy and Procedure for Document Scanning or Image Import • Competency of the scanning staff • Selecting the correct patient • Evaluating the document prior to scanning • Stamping the document • Following the Work Flow Process in the Capture window • Evaluating the scan • Final QA evaluation • Correcting Mistakes/scanning in a place holder/deleting the scan • Audits • To shred or not to shred

20. Auditing • Running Reports: • Significance of Reports • Did you know you can run a scanning report? • Do you know how to run a report?

21. Report Types • Document Counts: This is a report of the Image file (#2005) with images having an Image Type of 'DOCUMENT'. An ‘Acquisition Site’ and 'From' and 'To' Date/time Image Saved will be asked. Output includes: Acquisition Site, Date/Time Image Saved, Object Type (DOCUMENT), Type Index, and Image Saved By. There will be a total of the count of images that meet the sort criteria. • Image Type Count by User: This is a report of the Image file (#2005) of Image Types for an ‘Acquisition Site’ and a 'From' and 'To' Date/Time Image Saved date range. The report will give totals for each Acquisition Site, Object Type, for each user, within the Acquisition Site and date range. A grand total of images within the Acquisition Site and date range is given at the end of the report.

22. VistA Document Count Report

23. Captured By?

24. Errors and Deletion

25. Index Fields

26. Locked and Saved Configurations

27. Completed Scan Fields

28. Final QA

29. Non-Mandatory Fields Although Specialty and Procedure Event are not mandatory fields we strongly encourage that a site fills in the fields. The next slide will demonstrate rational for filling in the fields.

30. Image List: Type, Specialty, & Event Fields

31. Filters

32. Index Term Request Link • http://indextracker.imaging.med.va.gov:8080/indextracker/

33. Recent Patch Releases • Patch 59

34. Patches in Progress • Patch 72 • Patch 93 • Patch 94

35. Questions • Questions?