November 12, 2007

After the Storm
By Selena Chavis
For The Record
Vol. 19 No. 23 P. 24

When a powerful tornado crushed Georgia’s Sumter Regional Hospital, the HIM department was left to piece together what was left of its patient records.

When putting together disaster readiness and response strategies, many healthcare facilities plan for the worst. But who can predict what a facility may actually have to face? From water leaks and electrical fires to natural disasters and terrorist attacks, the term disaster can have a wide-ranging impact.

Large-scale disasters such as Hurricane Katrina have taught healthcare organizations that the unimaginable is possible and an effective medical records strategy is key to patient safety and continuity of care. This reality became further evident at Sumter Regional Hospital when a major disaster put its best-laid plans to the test.

On March 1, an F3 tornado slammed directly into the 143-bed acute care facility, which serves as the only hospital in the rural southwest Georgia community of Americus. Part of a storm system that had already killed eight students in Enterprise, Ala., a few hours earlier, the tornado left staggering damage in its wake—literally every room in the hospital was torn apart.

“The most important thing is that all of the hospital’s patients and personnel survived,” says Edward Farr, Sumter’s HIM director, who adds that with only a few minutes notice, hospital personnel were able to move all 53 patients from their rooms and into interior areas away from windows. “The actual physical building is still standing, but there is so much damage that it will have to be rebuilt.” The organization was serving patients through a mobile unit until an interim facility was scheduled to open this month.

The storm didn’t stop with the hospital either, inflicting damage throughout the community, including the newly opened Sumter HealthPlex, an 8,000-square-foot, $3.1 million facility that housed the hospital’s backup tapes. According to De Sears, assistant director of HIM, those tapes did not survive the storm. “That particular area was destroyed, and it also housed some of our medical records,” she notes. Fortunately, the records were not destroyed.

Sears says water leaks also caused damage in the hospital’s main medical records department, and some records stored in other heavily damaged areas were completely lost.

So what happens to the delivery of medical care in a small, rural community when it loses its only hospital? How does an HIM department respond to help stabilize the medical community?

Stepping Up Under Pressure
Immediately after the storm, the hospital worked out of tents to accommodate patients. “We set up a MASH [mobile Army surgical hospital] unit,” Farr recalls. “We kept those tents quite awhile before we could have mobile units brought in.”

During that time, the HIM department began to put the pieces back together. Sears recalls that the department’s saving grace rested in the fact that she had saved a copy of the master patient index (MPI) on her computer, which she took home with her the evening of the storm. “Having that piece was invaluable to us,” Farr says. “Without that, we wouldn’t have been able to look up records.”

Acting immediately also proved helpful as Sears made a point to go into the IT department and bag anything that was current or might have backup information. “Servers were pulled off the walls and placed in plastic bags to keep water off of them,” she recalls.

Damaged records were sent to Munters, a company that provides products and services for water and fire damage restoration. “The situation at Sumter was far more catastrophic than most,” says Steve Naughton, a Munters regional sales manager. “Your biggest enemy in these situations is always time.”

According to Naughton, the key to minimizing damage with paper records is to freeze the records as soon as possible to stop further damage. “Once frozen, you have time to make a decision,” he notes. “It’s difficult to access frozen records, but it can be done.”

At press time, patient records were still being housed by Munters, but the HIM department was planning to have the records moved to a company that was set up for transmitting information.

For a period of time following the disaster, Farr says every aspect of the HIM department went back 20 to 30 years. The hospital, which had previously been working in a hybrid records state where approximately 50% of patient records were electronic, immediately reverted to an all-paper environment. Coders had to return to “coding by the book” because the system was unavailable, and transcription was done via cassette tape dictation. In addition, an Excel spreadsheet was set up via the MPI to begin capturing patient data.

“It gave everyone an appreciation of the world we live in,” Farr says, adding that some records were simply lost. “In those situations, we did our best to re-create the records through the existing MPI and by talking to physicians and hospital staff.”

Eight months after the devastation, the hospital is currently providing urgent care, outpatient, and oncology services via its mobile unit as the staff anticipates this month’s opening of an interim facility. The HIM department is working out of a warehouse where current records are stored.

“We have gone back to a hybrid record. We are no longer printing out labs, radiology reports, and physician dictation,” Farr says. “The rest of the paper comes to our current HIM location and is filed into the unit record. Once we have inpatients again, we will continue to keep pieces of the record electronic. Our position will be: If the information can be accessed electronically, we will not print the paper.”

Farr says the department currently does not have any long-range plans to deal with the “current paper” as it pertains to scanning and archiving. “We just have not gotten that far yet in our planning,” he says.

Lessons Learned
Expect the unexpected, Sears says, adding that the staff at Sumter never envisioned being clobbered by a tornado. “Americus is known for being on top of a hill—no way it could ever be hit by a tornado,” she says. “We all took that to heart.”

In addition to the Sumter catastrophe, there was the destruction at the hospital’s HealthPlex complex, which added insult to injury and drove home a valuable lesson. “Keep backup information in a location other than the same town,” Sears says.

Sumter also learned the importance of identifying vendors prior to an event. Referring to recovery specialists such as Munters, Farr says, “I would suggest to any HIM professional to make a plan that you already have an established relationship with someone who can take care of that kind of stuff.”

Recalling that it was bombarded by calls and visits from vendors following the disaster, Farr notes that it took the facility a week to choose Munters during a situation when time was of the essence.

“Exchanging business cards on the side of a loss is not a good thing,” says Naughton. “When it happens, if you’ve already selected a provider, you’ve already got our credit … we’ve already got your credit … it just goes smoother.”

Munters has developed a preventive program called Code Blue, which Naughton says helps hospitals evaluate providers that can help them prepare and recover from a disaster. “The biggest challenge is to try and have a coordinated program,” he notes. “It’s a whole lot better for everybody if you get things moving quickly.”

Sears also notes that most hospitals are still storing some paper records, which increases the likelihood of loss when water is an issue. “Make sure if you live in the paper world that you have a tarpaulin,” she suggests, since some kind of protective covering that is easily and quickly accessed could save a lot of records.

Best Practice: Plan and Practice
Based on her experiences of trying to build a medical record for her stepfather following the devastation of Hurricane Katrina, Bonnie Sher, RHIA, CCS, CCS-P, CPC, says,“If ever there would be a place for an electronic record, it would be in an emergency.”

Recalling that Katrina left records floating in puddles of water, Sher says in the immediate aftermath, she had to visit doctors’ offices individually to get a handle on her stepfather’s health needs and medications at a time when he was taking 17 pills—at breakfast.

Now working on a disaster planning and recovery book in conjunction with the AHIMA, Sher says technology can solve many problems. “Gulfport (Miss.) Memorial has an electronic record. Once they had electricity, they were immediately back online,” she says.

Alongside the establishment of a clear, direct disaster plan specifically related to patient records, Sher points to the need to practice the plan. “Look at your plan for an emergency and practice, practice, practice … like the military,” she says.

Naughton agrees, adding that proper practice will also help facilities purge unnecessary records. “Make sure they are following their records policy,” he says, pointing to the need to maintain good daily inventory practices and destroy records after a certain period of time. “If you’re not sure what’s there, you’ll end up handling [the unnecessary] records. Then you have to go in and purge them before you can move forward.”

Having access to a document management solution can also be beneficial. Brett Griffith, president and chief operating officer of Pennsylvania-based Alpha Systems, notes that a document management vendor can help healthcare organizations by storing a snapshot of data on the company’s application service provider. “If they ever have a disaster, we have a complete set of their medical records,” he says, suggesting that facilities should make it a practice to capture data as quickly as possible—either during a patient stay or immediately thereafter—to mitigate risk. “If they have scanned and eliminated paper from the get-go, then there is nothing that is not easily replaced.”

— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications covering everything from corporate and managerial topics to healthcare and travel.

Avoid HIPAA Fallout During Disasters
Effective communication on numerous fronts becomes pertinent to patient safety and privacy during catastrophes. According to Bonnie Sher, RHIA, CCS, CCS-P, CPC, an HIM professional involved in the AHIMA’s myPHR project, HIPAA will allow healthcare facilities to relax the rules somewhat during disasters, but it really doesn’t equate to much leeway.

Sher suggests that organizations consider using their HIM director as the media point of contact during an emergency because “they will know what to say and what not to say.”

Health and Human Services released a bulletin in the wake of Hurricane Katrina that acknowledged the need for ready access to healthcare and also pointed out how the HIPAA Privacy Rule allows patient information to be shared in disaster situations.

Providers and health plans covered by the privacy rule can share patient information in the following ways:

Treatment
Healthcare providers can share patient information as necessary to provide treatment. Treatment includes sharing information with other providers, including hospitals and clinics; referring patients for treatment, including linking patients with available providers in areas where the patients have relocated; and coordinating patient care with others, such as emergency relief workers or others who can help find appropriate health services for patients.

Providers can also share patient information to the extent necessary to seek payment for these healthcare services.

Notification
Healthcare providers can share patient information as necessary to identify, locate, and notify family members, guardians, or anyone else responsible for care of the individual’s location, general condition, or death arrangements.

When possible, the provider should obtain verbal permission from individuals, but if the individual is incapacitated or unavailable, providers may share information for these purposes if, in their professional judgment, doing so is in the patient’s best interest. When necessary, the hospital may notify the police, press, or public at large to the extent necessary to help locate, identify, or otherwise notify family members and others as to the location and general condition of their loved ones.

In addition, when a provider is sharing information with disaster relief organizations such as the American Red Cross that are authorized by law or their charters to assist in disaster relief efforts, it is unnecessary to obtain a patient’s permission to share the information if doing so would interfere with the organization’s ability to respond to the emergency.

Imminent Danger
Providers can share patient information with anyone as necessary to prevent or lessen a serious and imminent threat to the health and safety of a person or the public—consistent with applicable law and the provider’s standards of ethical conduct.

Facility Directory
Healthcare facilities maintaining a patient directory can tell people who ask about individuals whether that person is at the facility, their location in the facility, and general condition. Of course, the privacy rule does not apply to disclosures if they are not made by covered entities. Thus, the rule does not restrict the American Red Cross from sharing patient information.

— SC

Guarding Against the Unguardable
According to Brett Griffith, Alpha Systems’ president and chief operating officer, there are practical steps providers can take to ensure they’re prepared for any disruption, particularly during hurricane season. His top 10 list includes the following:

1. Make sure all archived medical records are scanned and stored securely off site.

2. Along with implementing electronic medical records (EMRs), make sure important parts of the medical record that reside on paper, such as insurance documents, information generated internally (operating room notes and electrocardiogram strips), or other externally generated papers (referrals or advanced directives), continue to flow into the hospital system for a complete EMR.

3. Consider Computer Output to Laser Disk (COLD) feeds for data management, which allow hospitals to capture data residing in different systems and convert all these formats—even proprietary ones—into one common format.

4. Storing records should happen within 24 to 48 hours after a patient’s discharge.

5. Storage should provide anytime, anywhere access on an application service provider server for downtime access. Information extracted should also be stored on removable media (CD-ROM or DVD) on a server for quick access, when required.

6. In addition to raw data, storage backup should also maintain the index and audit trail as a part of backup service.

7. Make sure off-site storage facilities have backup power, stringent security features, fire and climate controls, ample communications, and bandwidth and server features to ensure 24/7 access.

8. Ensure data is in a common, interoperable format that can survive changes in technology.

9. Visit the backup facility to ensure that proper procedures and controls are in place.

10. Communicate your backup procedures with those who need fast access to patient information.