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Section 9. EMR

1. 07 01 03 Electronic Medical Record Management Item Category Indicator Evaluation Criteria 1 AD A staff assignment exists for each provider assignment There is at least 1 staff assignment under each provider assignment 2 AD Discharge pending approval is less than 14 days since author signature or is absent Discharges present and pending UM approval are less than 14 days old 3 AD Open provider assignment has active authorization to serve the case There is a provider assignment for each authorized provider Providers without active authorizations have been closed 4 AD Primary case holder is assigned for open case Open case has active primary case holder staff assigned 5 AD Primary provider is assigned for open case Open case has active primary provider assigned 6 AS If behavior treatment plan exists BRMC case notes are present according to BTP review schedule Review the BTP for the indicated BRMC review schedule The BRMC case review notes should be completed according to the specified BRMC review schedule 7 AS BRMC Case Review form is completed prior to discharge summary If discharge needs BRMC review the BRMC case review form is less than the discharge form date 8 AS If child CAFAS PECFAS assessment has occurred in last three months If the consumer is age 7 17 a CAFAS score is present If consumer is age 4 6 a PECFAS score is present Score should be recentl
2. incentive payment providers have to show that they are meaningfully using their EHRs by meeting thresholds for a number of objectives The Centers for Medicare and Medicaid Services CMS have established Meaningful Use objectives which are specific measurable ways in which an EHR can or must be used The EHR Incentive Programs are phased in three stages with increasing requirements Stage 1 Data capture and sharing Stage 2 Expand upon the Stage 1 criteria to encourage the use of health information technology and exchange for continuous quality improvement Stage 3 Expand on Stage 2 with a focus on promoting improved outcomes in quality safety and Efficiency Eligible professionals participate in the program on the calendar year while eligible hospitals and Critical Access Hospitals participate according to the federal fiscal year Providers must attest to demonstrating meaningful use every year to receive an incentive and avoid a Medicare payment adjustment Before an eligible professional can meet MU requirements they must acquire or have access to a CEHRT Certified EHR Technology EHR certification is conducted by an Office of the National Coordinator for Health Information Technology ONC Authorized Testing and Certification Body PCE Systems the vendor for LEO has received the Certificate of Compliance for the 2014 Edition ONC Health IT Certification Program issued by ICSAlabs If you wish to pursue Meaningful Use of the LEO syst
3. 01 None U F MDS A039 Primary Route of Administration A M usually 96 N A M F MDS A040 DU030 Primary Frequency of Use A M usually 96 N A M D E usually 96 N A E U usually 96 N A U F MDS A041 Primary Age at First Use A M usually 96 N A M F MDS A042 DU031 Secondary Substance Use Problem A M usually 01 None M D E usually 01 None E U usually 01 None U F MDS A043 Secondary Route of Administration A M usually 96 N A M F MDS A044 DU032 Secondary Frequency of Use A M usually 96 N A M D E usually 96 N A E U usually 96 N A U F MDS A045 Secondary Age at First Use A M usually 96 N A M F MDS A046 DU033 Tertiary Substance Use Problem A M usually 01 None M D E usually 01 None E U usually 01 None U F MDS M w Int Tx M record for individual receiving integrated MH SA treatment funded w MH Dollars Only Field Requirements Color Coded 07 14 15 Page 2 of 3 SUD SUD T1 T2 Field Name A M M w Int Tx D E E MH w Int Tx U MH U MH w Int Tx Mental Health Mental Health Federal Data Set Field ID F Federal or S State Field Admission Discharge Update A047 Tertiary Route of Administration A M usually 96 N A M F MDS A048 DU034 Tertiary Frequency of Use A M usually 96 N A M D E usually 96 N A E U usually 96
4. Dictionary Manager Address Book Manager Treatment Plans Progress Notes Medical Chart Information Systems Specialist 517 780 3367 Insurance Billing PSU Consumer Billing Account Balance Injection Billing Children s Waiver Billing Billing Specialist 517 789 2481 Encounters QI Data Clean Up Report Requests Database Administrator 517 789 1268 Consumer Authorizations Self Determination Provider Assignments Chief Operating Officer 517 796 4574 Calendars PSU Demographics PSU Clinical Support Services Supervisor 517 796 4558 Lab Results BRMC Review RN Supervisor 517 780 3360 LifeWays Community Mental Health Provider Manual EMR 27 8 LEO BULLETINS The LEO News Bulletin is published on the LifeWays website and emailed to the EMR List Serv Bulletins will be archived on the LifeWays website for future reference and instruction LEO News Bulletins are published monthly and contain valuable information regarding LEO and changes or upgrades to LEO All providers are encouraged to sign up for LEO Bulletins as this is the main communication modality for changes or alerts regarding LEO To receive the LEO Bulletins go to www lifewayscmh org and select LifeWays e Newsletter 9 SYSTEM ENHANCEMENTS amp RECOMMENDATIONS All recommendations for system enhancements shall be directed to LifeWays Director of Quality Improvement amp Information Technology via the System Change Request form The process for
5. Leader will determine validity and notify Customer Services If approved the subpoena copy will be forwarded to Customer Services indicating it is a valid subpoena and to process Per the instructions of the Recipient Rights Manager Customer Services shall copy the information and forward to the Clinical Director for approval If approved a copy of the subpoena the copied records and a cover letter Attachment A is mailed to the person agency The Released Information form is completed and stapled to the original subpoena with a copy of the cover letter The information is filed in the Consent and Authorizations section of the medical record Page 2 of 3 LifeWays Operating Procedures CHAPTER GOVERNING POLICY 6 00 Consumer Services 03 Medical Record Management SUBJECT 01 Medical Record Release of Information EFFECTIVE DATE 09 30 1997 REVIEWED REVISED 04 12 2012 Note There is usually a check sent with the subpoena Determine the copying charge amount and if it is less than the check amount subtract the check amount from the copying charge to determine their balance and send the person agency a letter stating the amount owed REFERENCES Forms Found Release Notice Released Medical Records Worksheet Form 1023 Consent for the Mutual Release of Confidential Information Form 1009 Incorrect Language Letter Letter No Record of Person HISTORY Effective 09 30 1997 Rev 3 01 6 02 2 03 6 07 9 07 8 08 1 09 9
6. Quality Improvement amp Technology Services Page 1 of 9 LifeWays Operating Procedures SECTION GOVERNING POLICY 7 00 Information Systems IS 01 IS Infrastructure Strategy and Management SUBJECT 03 Electronic Medical Record EMR Management EFFECTIVE DATE 03 01 2014 REVIEWED REVISED 11 01 2014 User Setup The agency is responsible for the oversight and establishment of access levels and permissions within the EMR system The LifeWays Information Systems Specialist is responsible for user setup granting permissions and ongoing monitoring to ensure security and privacy is upheld User setup shall be a centralized role within the agency that is managed by the IT team Provider Administrator LifeWays may choose to delegate the setup and management of provider staff users to a designated and trained Provider Administrator at each provider agency This is considered a privileged function high ethical standards and security practices must be applied within this role These permissions can be removed at any time by the agency The Provider Administrator must follow the user setup manual provided by LifeWays The Provider Administrator is expected to strictly adhere to LifeWays guidelines regarding creation and management of functional access and privileges for users LifeWays shall monitor the Provider Administrators user setup audit trails and the integrity of their managed users to ensure security and privacy is upheld within user acc
7. Security Number A M M D E E U U S A007 DU007 Medicaid ID S A008 DU008 MIChild ID S A009 DU009 Medicare ID S System Data Set A010 DU010 SDA SSI SSDI Enrollment A M M D E E U U S Minimum Data Set A011 DU011 Service Start Date A M M D E E U U F MDS Suplemental Data Set A012 DU012 Service Start Date Time of Day A M M D E E U U S A013 Time to Treatment A M M F SuDS A014 Referral Source A M M F MDS A015 Detailed Criminal Justice Referral A M M F SuDS A016 DU013 Type of Treatment Service Setting A M M D E E U U F MDS A017 DU014 Codependent Collateral Person Served A M always 2 Client M always 2 Client D E E U U F MDS DU015 Date of Service Update End D E E U U F MDS DU016 Service Update End Time of Day D E E U U S DU017 Reason for Service Update End D E E U U F MDS A018 DU018 ID DD Designation A M M D E E U U S A019 DU019 MI SED Designation A M M D E E U U S A020 DU020 Detailed SMI SED Status A M M D E E U U F MHA A021 Prior Treatment Episodes A M M F MDS A022 Date of Birth A M M F MDS A023 Gender A M M F MDS A024 Pregnant at Service Start Date A M M F SuDS A025 County of Residence A M M S Mental Health Specific Admission Set SUD and MH and Situational BH TEDS Fields Mental Health Mental Health Federal Dat
8. change is illustrated in the attachment Change Control Process Flowchart Attachments 07 01 03 C System Change Request form 07 01 03 B Change Control Process Flowchart 10 SECURITY AND PROTECTION OF PHI All LifeWays staff and provider network shall comply with LifeWays policy and procedure for Uses and Disclosures of Protected Health Information Link 7 02 06 Uses and Disclosures of Protected Health Information You will find this option near the bottom left of the home page Once selected you will be prompted for contact information and able to choose which newsletters you wish to receive LifeWays Community Mental Health Provider Manual EMR 28 11 RELEASE OF INFORMATION A valid Release of Information form must be on file before any documents can be released A release can be generated from LEO by going under Consents to Participate Exchange Information Once you have chosen the consumer Releases are time limited so be sure to verify validity of the release if using one already on file Refer to the Procedure below when releasing information Link 6 03 01 Medical Record Release of Information 12 MEANINGFUL USE The goal of Meaningful Use is to improve patient care by meaningfully using an electronic medical record The Medicare and Medicaid Electronic Health Record EHR Incentive Programs provide financial incentives for the meaningful use of certified EHR technology to improve patient care To receive an EHR
9. direction of change between two points in time This single data collection system for mental health and substance use treatment services utilizes the federal coding requires and additional Michigan specific fields deemed necessary The coding of these fields will now be the same whether mental health or substance use This has been repeatedly requested by CMHSPs for many years Data is submitted to the Federal Government at the Time 2 point The data is analyzed on a national state and local level Link Copy of BH TEDS Field Requirements Link Procedure 7 01 03 Electronic Medical Record 7 HELP DESK The LEO Help Desk is intended to provide technical assistance and troubleshooting of system errors for traditional business operations that currently exist within the EMR LEO LifeWays Help Desk staff shall maintain high standards for timeliness of response and resolution and maintain open communication with the user regarding attempts made to resolve the help desk ticket The LEO Help Desk is not designed to field system enhancements or suggestions from end users Several How To Guides are available for LEO users and may assist the user without the need of IT Support These guides can be accessed when in LEO by clicking If the user is unable to self resolve the issue the user shall The LEO Help button at the top of the LEO Home page provides access to detailed instructions for several common issues related to LEO LifeWays Commu
10. info to the physician is completed electronically or scanned into the record and is current 18 CR Diagnosis Axis are complete Axis 1 5 The full diagnosis table is complete including Axis I II III IV and V 19 CR Advanced Directive status is collected and scanned into the chart is active Review the most recent consent to participate If the consumer indicates that they have an active advanced directive a copy is scanned into the consumer chart 20 CR Scanned documents are appropriately categorized and organized Review each scanned document that was entered during the current treatment plan and verify that the Document Type appropriately matches the content of the scanned image The date of the document should match the date within the document and not the date it was scanned There should be no duplication of scanned documents 21 CR Care coordination communication form is used and scanned into LEO in accordance with consents to release info i e beginning services medication changes hospitalizations discharges Care coordination is evident by a health care coordination form document in the record 22 CR If guardian is present there is guardianship papers are on file If a guardian is indicated in the Consumer Information there are guardianship papers scanned into the consumer chart 23 CR No documents awaiting disclosure in the Medical Record queue The requested documents have been rel
11. it by Call Manager 1 The system will not be fully functional until Call Manager 1 is back online Call Manager 2 ensures that critical services such as dial tone and the ability to make and receive calls remain up The two systems are connected in a virtual server environment Voice mail is provided to the system through a Cisco Unity Connection Voice Mail Server LifeWays staff maintains these systems with support through a contract with NuWave Technology Partners When either system fails LifeWays IT staff will evaluate the failure and either make repairs or contact NuWave Technology Partners using the following Call 877 342 4401 Use as much detail as available to explain the problem Typically when a problem develops with the actual telephones lines another call may be needed to the phone company for repairs Should there be a complete failure of lines or other catastrophic event extended power outage contact NuWave Technology Partners at the above number to have the lines forwarded offsite as per Attachment A for the Telephone System LifeWays currently utilizes a 10 megabits per second IP Flex circuit to carry its phone and data traffic This circuit is provided by AT amp T at the Jackson location These lines are answered by the phone system and all incoming calls are then distributed to the desktop telephones All outgoing calls also utilize the same circuit that has the capacity to support multiple calls All calls delivered by the cir
12. note that there are no DSM 5 codes Rather there are new descriptions that need to be mapped to ICD Our system is currently setup to accommodate a description for each code Use of DSM is a clinical professional decision as billing is still done using ICD The state workgroup is recommending a go live date of 10 1 2015 Expected Future Changes The axial format would be removed from the LEO forms The SAL billing form on the document will be updated to include diagnosis lookup so the clinician can specify the exact diagnosis addressed in that contact Need to determine what replaces the Axis VI psychological and environmental factors A DSM task force has recommended using a set of V codes and Z codes from the ICD Need to determine what replaces the Axis V GAF score A DSM task force is piloting the WHODAS World Health Organization Disability Assessment LifeWays is joining a PCE workgroup and continuing participation on the TSG The Standards Group state workgroup to follow and implement changes Providers and LifeWays staff should continue to seek out clinical training opportunities for DSM 5 LEO Quality and Integrity Standards for Electronic Medical Records LifeWays EMR Standards 1 Effective 8 1 2013 Purpose The following table identifies the minimal standards necessary to determine an electronic medical record as complete and accurate Reference LifeWays Operating Procedure
13. or obtaining a copy or both in designated record sets If the same PHI requested is LifeWays Operating Procedures CHAPTER GOVERNING POLICY 6 00 Customer Services 03 Medical Record Management SUBJECT 02 Consumer Access to Medical Records EFFECTIVE DATE 12 01 2013 REVIEWED REVISED 11 01 2014 Page 3 of 5 maintained in more than one designed record set or at more than one location LifeWays will only provide the requested PHI once in response to a written request for access c LifeWays must provide the designated record sets in hard copy or electronic format as requested by the individual If electronic format is required LifeWays shall load requested information on an encrypted password protected flash drive d LifeWays must provide the Individual with access to the PHI in the form or format requested by the Individual if it is readily producible in such form or format If the information requested is not readily producible in the requested format then LifeWays and the Individual will agree on an alternative format If for good reason LifeWays cannot agree to any format requested by the Individual LifeWays shall provide the PHI in the format LifeWays reasonably believes is most like that requested by the Individual and which is practical under the circumstances e LifeWays may provide the Individual with a summary of the PHI requested in lieu of providing access to the PHI or may provide an explanation of the PHI to
14. psychiatric LEO Quality and Integrity Standards for Electronic Medical Records LifeWays EMR Standards 4 Item Category Indicator Evaluation Criteria months for consumers receiving Psychiatric services evaluation is present there are vital signs recorded within the last 12 months 48 PG Progress notes are present for all active providers Review authorized providers and cross reference with the progress note module A progress note should be present for all active authorized providers The progress notes should be entered electronically if a e format for the note is available otherwise a scanned progress note is accepted 49 TP Residential quality of life assessment was completed by residential staff prior to PCP meeting If consumer has specialized residential services verify in demos and the treatment plan shell header there is a residential quality of life assessment included in the treatment plan and it was completed by the residential staff before the date of the PCP meeting 50 TP Consumer signatures are obtained digitally or scanned in as an Attachment to the Treatment plan Consumer s signature can be found within the Treatment Plan print or as a scanned document within the Attachments 51 TP Copy of treatment plan is provided to consumer Treatment plan shell header displays the date and method in which the copy of plan was provided 52 TP Notice of Hearing Rights is signed
15. the occurrence O of the problem the number of times the problem or condition non conformance occurs during the defined process cycle within the scope of the element 5 Very High 80 or more of the time 4 High 60 79 3 Moderate 40 59 2 Low 20 39 1 Minor 0 19 3 Determine the number N of consumers and or customers affected The number of consumers and or internal external customers affected by the problem or condition non conformance during a defined period of time within the scope of the element 5 Very High 80 or more of consumers 4 High 60 79 3 Moderate 40 59 2 Low 20 39 1 Minor 0 19 LEO System Change Request Form LifeWays LEO System Change Request Form 2 Priority Ranking Score PRS S x O x N Design amp Planning Description of design and planned change Purpose of the change Attachments Screen layout Process diagram Instruction manual with business rules Screencasting video Prototype Testing amp Pilot Development System Effective Date Summary of input from testing and subsequent modifications Implementation amp Training Production System Effective Date Included in News Bulletin Training materials posted on website Sustainment Planned Evaluation Date Measures used to determine success Results of evaluation References LifeWays Operating Procedure 07 01 03 Electronic Medical Record Management LifeW
16. 0 minutes allowing time for orderly shutdown of the systems Only the computers in the server room are powered from the UPS all client computers will be immediately affected in the case of a general loss of power from Consumers Energy The telephone system is connected directly to a UPS device in the Main Distribution Facility MDF and in each intermediate distribution frame IDF The UPS devices will automatically deliver power to the phone system for a period of approximately 20 minutes after which the phone system will shut down if power has not been restored 3 Backup amp Restore LifeWays currently backs up its mission critical systems on a daily basis Backup drives are kept offsite All data operating systems and utility files must be adequately and systematically backed up including all patches fixes and updates Records of what is backed up and to where must be maintained Records of software licensing is backed up The backup media must be precisely labeled and accurate records must be maintained of back ups done and to which back up set they belong Copies of the backup media together with the backup record should be stored safely in a remote location at a sufficient distance away to escape any damage from a disaster that may occur at the main site Regular tests of restoring data software from the backup copies should be performed to ensure reliability in the event of an emergency All Li
17. 09 Page 3 of 3 LifeWays Operating Procedures CHAPTER GOVERNING POLICY 6 00 Customer Services 03 Medical Record Management SUBJECT 02 Consumer Access to Medical Records EFFECTIVE DATE 12 01 2013 REVIEWED REVISED 11 01 2014 Page 1 of 5 6 03 02 CONSUMER ACCESS TO MEDICAL RECORDS PURPOSE To establish a mechanism for the Consumer parent or legally authorized representative to request access for review or photocopying of the Consumers health and or financial information DEFINITIONS Consumer refers to the person who is the subject of the Protected Health Information Designated Record Set means 1 a group of records including any item collection or grouping of information that includes Protected Health Information maintained collected used or disseminated by LifeWays that is a The medical records and billing records about an Individual maintained by or for LifeWays b The enrollment payment claims adjudication and case or medical management record systems maintained by or for LifeWays or c Used in whole or in part by or for LifeWays to make decisions about Individuals Individual refers to the person who is the requestor of the protected health information and may include any one of the following the Consumer if the Consumer is over the age of 18 years legally emancipated or there are other circumstances under Michigan law which allow a minor patient to access his her own record the
18. Consumer s parent if the Consumer is under the age of 18 years the Consumer s appointed guardian regardless of Consumer s age or the Consumer s personal representative Protected Patient Health and Financial Information PHI means any information whether verbal or recorded in any form or medium that is created or received by a health care provider health plan public health authority employer life insurer school or university or health care clearing house and relates to the past present or future physical or mental health or condition of an Individual the provision of the health care to an Individual or the past present or future payment for the provision of health care to an Individual PROCEDURE An Individual shall be able to make a written request for inspection and or copies of a Consumer s PHI and financial information This request is completed through the Application For Access to Recipient Case Record Information form Such access shall be granted for inspection or requested copies by LifeWays unless the request is denied by a licensed health care professional There are two types of denials non reviewable or reviewable as documented in this policy LifeWays Operating Procedures CHAPTER GOVERNING POLICY 6 00 Customer Services 03 Medical Record Management SUBJECT 02 Consumer Access to Medical Records EFFECTIVE DATE 12 01 2013 REVIEWED REVISED 11 01 2014 Page 2 of 5 LifeWays cont
19. INUITY AND DISASTER RECOVERY PURPOSE Each division within the agency is responsible for creating maintaining and testing its business continuity and disaster recovery plans in order to effectively resume operations during a disaster or service disruption The Information Technology IT Team is responsible to provide successful contingency plans in the event that the agency s information system infrastructure is compromised The contingency plan shall include technical capabilities designed to support contingency operations The procedure includes best practices to mitigate the agency s risk of disruption to the continuity of business operations and shall be maintained tested and evaluated periodically INFORMATION TECHNOLOGY DEPARTMENT RESPONSIBILITIES The IT Information Technology Department is responsible to maintain a detailed IT Disaster Recovery Plan that identifies responsibilities of key personnel response procedure methods to evaluate effectiveness of response and recommendations for contingency operations until business is restored The IT Department will work with the Disaster Management Coordination a designee of the CEO to implement contingency plans and works towards systems restore BEST PRACTICES TO MITIGATE DATA LOSS AND SYSTEMS COMPROMISE The IT Department will implement the following practices to mitigate data loss when the IT systems have been compromised 1 System Security Currently LifeWays systems require valid lo
20. LifeWays Community Mental Health Provider Manual EMR 23 Electronic Medical Record EMR 1 ROLE OF THE IT DEPARTMENT The Information Technology IT department is responsible for the infrastructure strategy and management of the EMR The IT department hosts the Help Desk and provides customer service to providers utilizing LEO LifeWays EMR The IT department sets up new users including user names passwords and permissions terminates users and provides technical assistance The IT department works with leadership to enhance the EMR and trouble shoot process issues and pushes out upgrades and security protections to all LEO users as needed and required The IT department will make every attempt to reduce interruptions to business operations and do required maintenance during off hours 2 LEO OVERVIEW The LifeWays Electronic Organizer LEO is the electronic medical record EMR used by LifeWays and the provider network These terms LEO and EMR may be used interchangeably when referring to LifeWays medical record system LEO is an internet based system 3 PROVIDER ACCESS AND PERMISSIONS A LEO Administrator can add new staff and expire terminated or resigned staff A LEO Administrator can also choose permissions for staff within LEO Please contact your LEO Administrator for more information 4 PROVIDER LEO TRAINING New providers can request training from LifeWays by contacting the LifeWays Help Desk at 517 780 3367 Th
21. N A U F MDS A049 Tertiary Age at First Use A M usually 96 N A M F MDS A050 Medication assisted Opioid Therapy A M 6 N A M F MDS A051 Integrated Substance Use and Mental Health Treatment A M M F SuDS A052 DU035 Living Arrangements A M M D E E U U F SuDS A053 DU036 Detailed Residential Care Living Arrangement A M M D E E U U S A054 DU037 Arrests in Past 30 Days A M M D E E U U F SuDS A055 DU038 Corrections Related Status A M M D E E U U S A056 DU039 Attendance at Self help Groups in Past 30 Days A M usually 96 N A M D E usually 96 N A E U usually 96 N A U F SuDS A057 DU040 Diagnostic Code Set Identifier A M M D E E U U F SuDS A058 Substance Use Diagnosis A M M F SuDS A059 DU041 MH Diagnostic Code One A M M D E E U U F MHA A060 DU042 MH Diagnostic Code Two A M M D E E U U F MHA A061 DU043 MH Diagnostic Code Three A M M D E E U U F MHA A062 Legal Status at Admission to State Hospital A 96 N A M M F MHA A063 DU044 Error ID S A065 DU045 Filler A M M D E E U U S Enter Error ID when applicable otherwise blanks M w Int Tx M record for individual receiving integrated MH SA treatment funded w MH Dollars Only Field Requirements Color Coded 07 14 15 Page 3 of 3 LifeWays Operating Procedures SECTION GOVERNING POLICY 7 00 In
22. The System Change Request form is completed System analysis is conducted to validate the request 2 System Concept Determines feasibility Defines the scope or boundary of the concept Page 6 of 9 LifeWays Operating Procedures SECTION GOVERNING POLICY 7 00 Information Systems IS 01 IS Infrastructure Strategy and Management SUBJECT 03 Electronic Medical Record EMR Management EFFECTIVE DATE 03 01 2014 REVIEWED REVISED 11 01 2014 Development Determines impact expected outcomes and measures for success The System Change Request form is updated 3 Design and Planning The functions and operations are described in detail including screen layouts business rules process diagrams and other documentation A prototype is created for the Development system The System Change Request form is updated to reflect the implementation and communication plan 4 Prototype Testing and Pilot The prototype is loaded in the Development system for user testing and training Additional modifications are requested from the developer as necessary to meet the expected outcomes Input is received from primary end users 5 Implementation and Training The tested prototype is deployed to the Production system on a scheduled date End users receive communication and instructional material from the agency for training purposes 6 Sustainment The change is re evaluated for success based on the previously defined outcome mea
23. The request for psychotherapy notes b Information compiled in reasonable anticipation of or for use in a civil criminal or administrative action or proceeding c An inmate s request to obtain a copy of PHI if obtaining such copy would i jeopardize the health safety security custody or rehabilitation of the individual or of other inmates or ii jeopardize the safety of any officer employee or other person at the correctional institution or responsible for the transporting of the inmate d Protected health information contained in records that are subject to the Privacy Act 5 U S C 552a may be denied if the denial of access under the Privacy Act would meet the requirements of that law or e The protected health information was obtained from someone other than a health care provider under a promise of confidentiality and the access requested would be reasonably likely to reveal the source of the information 5 Reviewable Grounds for Denial LifeWays may deny an individual access provided that the individual is given a right to have such denials reviewed in the following circumstances a A licensed health care professional has determined in the exercise of professional judgment that the access is reasonably likely to endanger the life or physical safety of the individual or another person b The PHI makes reference to another person unless such other person is a health care provider and a licensed health care professio
24. a Set Report if individual has known identifier whether or not currently enrolled and or eligible Field ID F Federal or S State Field Admission Discharge Update Federal Unduplicated Client Count Calculations M w Int Tx M record for individual receiving integrated MH SA treatment funded w MH Dollars Only Field Requirements Color Coded 07 14 15 Page 1 of 3 SUD SUD T1 T2 Field Name A M M w Int Tx D E E MH w Int Tx U MH U MH w Int Tx Mental Health Mental Health Federal Data Set Field ID F Federal or S State Field Admission Discharge Update A026 Race A M M F MDS A027 Hispanic or Latino Ethnicity A M M F MDS A028 DU021 Mainstream Special Education Status A M M D E E U U S A029 DU022 Education A M M D E E U U F MDS A030 DU023 School Attendance Status A M M D E E U U F MHA A031 Marital Status A M M F SuDS A032 Veteran Status A M M F SuDS A033 DU024 Employment Status A M M D E E U U F MDS A034 DU025 Detailed Not in Competitive Integrated Labor Force A M M D E E U U F SuDS A035 DU026 Minimum Wage A M M D E E U U S A036 DU027 Total Annual Income A M M D E E U U S A037 DU028 Number of Dependents A M M D E E U U S A038 DU029 Primary Substance Use Problem A M usually 01 None M D E usually 01 None E U usually
25. act person c If LifeWays does not maintain the PHI that is the subject of the individual s request for access and LifeWays knows where the requested information is maintained must inform the individual where to direct the request for access d If the individual has requested a review of a denial LifeWays will designate a licensed health care professional who was not directly involved in the denial to review the decision to deny LifeWays Operating Procedures CHAPTER GOVERNING POLICY 6 00 Customer Services 03 Medical Record Management SUBJECT 02 Consumer Access to Medical Records EFFECTIVE DATE 12 01 2013 REVIEWED REVISED 11 01 2014 Page 4 of 5 access LifeWays must promptly not longer than thirty 30 calendar days refer a request for review to such designated reviewing official The designated reviewing official must determine within a reasonable period of time not longer than thirty 30 calendar days whether or not to deny the access requested LifeWays must promptly not longer than thirty 30 calendar days provide written notice to the individual of the determination of the designated reviewing official and take other action as required by this section to carry out the designated reviewing official s determination 4 Non Reviewable Grounds for Denial of Access to PHI LifeWays may deny an individual access without providing the individual an opportunity for review in the following circumstances a
26. andards for Electronic Medical Records LifeWays EMR Standards 3 Item Category Indicator Evaluation Criteria 32 FI A current self pay financial determination is complete verified by LifeWays Self pay is present and includes the consumer s signature that is obtained digitally or is scanned in as an attachment to the policy Supporting financial documentation is scanned in as an attachment to the policy 33 FI Insurance policies are verified All insurance policies for the case are Verified and not in Awaiting Verification status 34 FI Medicaid deductible policy is present if the consumer is on a deductible If the consumer is on a Medicaid deductible there is a Deductible policy entered in the insurance policy area and it is not expired until the deductible no longer applies 36 IR Incident Reports are routed for signature and reviewed signed in a timely matter Search IR module for all incident reports for the consumer and verify that they have been fully reviewed by all Reviewers as indicated by a Review Date next to each reviewer The Review Date should not be null 37 MC Medication consents are present and include consumer and medical staff signature for all current medications Review the most recent Medication Review to determine the medications that are active then review the Signed Medication Consents in the Medical Chart to determine if there s a signed consent for each active medicati
27. are complete A selection is present for every health condition listed in the health amp other conditions page 12 AS If consumer is authorized for a BTP there is a BTP scanned into LEO If consumer is authorized for H0032 BT there is a scanned BTP in the scanned document file 13 AS Psychiatric inpatient stays are managed through continued stay reviews and hospital discharge planning If psychiatric inpatient authorization is present there is a continued stay review and hospital discharge from 14 CR Chart Notes are used appropriately for miscellaneous documents or chart warnings If a chart note is present in the record it is for miscellaneous purposes and not billable documentation or information that is applicably stored elsewhere 15 CR Consent to participate is present Consents to participate for all active providers are LEO Quality and Integrity Standards for Electronic Medical Records LifeWays EMR Standards 2 Item Category Indicator Evaluation Criteria completed electronically or scanned into the record 16 CR If consumer is enrolled in school K 12 there is consent to release information to the school present Consents to exchange release info to the child s school is completed electronically or scanned into the record and is current 17 CR If consumer reports a primary care physician consent to release information to the physician is present Consents to exchange release
28. ays Operating Procedures SECTION GOVERNING POLICY 7 00 Information Technology 02 Information Security and Risk Management SUBJECT 06 Uses and Disclosures of Protected Health Information EFFECTIVE DATE 03 10 2010 REVIEWED REVISED 07 02 06 USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION PURPOSE The purpose of this operating procedure is to outline the process for the proper disposal of paper records documents and data that convey confidential medical information in accordance with HIPAA regulations state laws and internal confidentiality policies OBJECTIVE Title II of HIPAA Health Insurance Portability and Accountability Act known as the Administrative Simplification AS provisions requires the establishment of national standards for electronic health care transactions and national identifiers for providers health insurance plans and employers The Administration Simplification provisions also address the security and privacy of health data DEFINITIONS A Legally Protected Information 1 Patient care records including mental health records medical records referral forms research records practitioner notes pharmaceutical prescriptions and any document or material that contains consumer identification name address phone number and diagnostic information 2 Peer review quality management utilization review risk management credentialing files 3 Regulatory reports incident reports unusual occurre
29. by consumer and scanned in as an Attachment to the Treatment plan including subsequent Addendums Signed paper notice is scanned is as an Attachment to the treatment plan or plan addendum 53 TP Treatment plan formal review has occurred quarterly since treatment plan effective date A formal review was completed every 3 months using the electronic form since the treatment plan effective date 54 TP Treatment plan is fully signed by provider staff Treatment plan is entered electronically not scanned and is not pending staff signature End 1 Initiation Define need Initiate system concept Define scope Prioritize 2 System Concept Development Assess value and feasibility Recommend solution Define impact and expected outcomes Define measure for success Schedule according to priority list 5 Implementation amp Training Deployed to Production system Communicated through News Bulletin Training materials published on website 4 Prototype Testing amp Pilot Development system test Input from primary users Subsequent revisions Electronic Medical Record Management System Change Control Process Flowchart August 1 2013 LifeWays System Enhancement No Refer to Help Desk Close Yes Approve Enhancement No Yes 6 Sustainment Re evaluate change Seek input from primary users Subsequent revisions 3 Design amp Planning Define change D
30. cal Record EMR Management EFFECTIVE DATE 03 01 2014 REVIEWED REVISED 11 01 2014 07 01 02 Reporting Services 07 02 02 Information Access and Systems Security 07 02 06 Use and Disclosures of Protected Health Information 07 02 07 Mobile and Portable Systems and Security 07 03 02 Information Systems Service Desk Forms LEO Systems Change Request Attachments LEO Quality and Integrity Standards for Electronic Medical Records System Change Control Process Flowchart System Change Request form LEO Instructional Materials How To Guides How to Update Consumer Demographics How to Add an Admission Provider Assignment Staff Assignment and Discharge a Consumer How to Add an Initial Intake How to Add Consumer Notices How to Change a Signed Document How to Early Terminate an Authorization How to Navigate the Consumer Chart How to Add Request Authorizations How to Update the Intake How to Update a Consumer s Diagnosis How to Add Consumer Allergies Adverse Reactions How to Add DD Proxy Measures How to Complete a Service Activity Log How to Complete a CAFAS PECFAS Assessment How to Use Discussions How to Use Electronic Labs Flow Charts Access Center Screening Process Flow Access Center Intake Process Flow Utilization Management Process Flow PSU Support Staff Process Flow Provider Clinical Process Flow Provider Claims Process Flow FAQ User Manuals Login and Navigation User Manual Access Screenings Crisis Intervent
31. consents will become mandatory Consent to Exchange Release Information Consent to Participate in Services Scanned Documents If a particular electronic form does not exist in the system the user may scan in their version of the form to complete the electronic record It is expected that scanned documents are consistently uploaded using the appropriate category type to enhance the organization of these images Each scanned document page shall include the consumer s name and case number Additionally the date of the scanned document shall match the date of the scanned image for historical archiving Timeliness of Signed Documents Users shall recognize the importance of completing clinical documentation soon after the contact with the consumer Unsigned documents negatively impact billing encounter reporting timeliness reporting and other areas of performance As a result LifeWays has adopted a timeliness standard for clinical forms in LEO to be completed within 3 business days from the date of service Therefore clinical documents must be fully executed completed and signed within 3 business days of the date of service The first exception to this rule are crisis interventions which must be completed within 24 hours from the time of disposition The second exception to this rule are progress monitoring notes for specialized outpatient services specifically RN RD BT and OT services which must be completed within 5 busine
32. ction allergies have been recorded within the last 12 months If no allergies this is accurately recorded as NKDA No Know Drug Allergies as the Drug Allergen 40 MC Dispense notes are present for injectable medications If consumer is prescribed an Injectable Medication dispense notes are present to record the dispensing at the frequency noted within the prescription 41 MC Lab results are scanned or electronically transmitted results are reviewed by ordering physician If consumer has a Lab Order in LEO there is a corresponding Lab Result that has been reviewed by the ordering physician 42 MC CMH medications are present and current and align with the most recent medication review note Review last medication review and cross walk with the CMH prescribed medications for accuracy and completeness 43 MC No lab results awaiting review There are no lab results for the case that are Pending Review in the medical chart 44 MC Non CMH medications are present and current consumer self reports Review last medication review and cross walk with the non CMH prescribed medications for accuracy and completeness 45 MC Initial Psychiatric Evaluation is present A psychiatric evaluation is present 46 MC No verbal orders awaiting review There are no verbal orders awaiting the physician s approval for the case 47 MC Vital signs have been completed in last 12 If authorization for medication review or
33. cuit are handled by the Call Managers and routed to the appropriate phone extension or call group All calls come in and out of the network on the PRIs The PRI Primary Rate Interface is circuits are labeled as follows gt This is a Single Unlimited local PRI gt This is 2 unlimited local PRIs The following is a list of Phone Direct Inward Dialing DID that are associated with the above PRIs LW Jackson DID Range s 517 789 1200 1239 517 789 1260 1299 517 789 2480 2499 517 780 3300 3399 517 796 4500 4599 Page 3 of 4 LifeWays Operating Procedures SECTION GOVERNING POLICY 7 00 Information Systems IS 02 IS Security and Risk Management SUBJECT 01 Business Continuity and Disaster Recovery EFFECTIVE DATE 08 21 2002 REVIEWED REVISED 03 01 2014 PROCEDURE FOR FORWARDING TELEPHONES In the event there is an evacuation order for 1200 N West Avenue the following should be done to forward LifeWays telephones to a backup location Currently the only number that is set up for forwarding to an Alternate Location is the Crisis Line To forward the Crisis Line to our after hours site Gryphon Place perform the following task Call the AT amp T CLAR phone number at 517 483 9994 When prompted enter the following pin 99999999 When prompted enter the following plan 1111 At the end of the crisis when the evacuation order has been lifted and the building at 1200 N West can again be occupied follow these steps to un for
34. e Information Systems Specialist will provide an overview to LEO and highlight general areas of use Currently LifeWays utilizes a Peer to Peer model for more specific training Please contact your supervisor for LEO training related to your specific job Training classes are in development Please refer to upcoming LEO Bulletins or Process Alerts or the LEO Website for updates on topics and registration information 5 EMR QUALITY AND INTEGRITY STANDARDS There are a minimum of 54 standards necessary to determine an electronic medical record complete and accurate Those standards are referenced below Attachment 7 01 03 A LEO Quality and Integrity Standards for Electronic Medical Records LifeWays Community Mental Health Provider Manual EMR 24 6 DATA REQUIREMENTS SAMHSA s Synectics BH TEDS Behavioral Health Treatment Episode Data Set Award Agreement with MDHHS is an evolution of the Substance Use Substance Use Agreement to expand and include client level mental health data in addition to the substance use data that s been collected in Michigan for 25 years BHDDA leadership has decided that the national effort to combine these systems coupled with the advent of P A 500 and 501 provided an excellent opportunity to combine the substance abuse and mental health SU TEDS and QI Data demographic files into a single system with a single coding schema Based upon a Time 1 Time 2 architecture BH TEDS is used to measure the magnitude and
35. e the link Forgot My Password on the login screen to reset it and obtain a temporary password If you have been locked out due to many unsuccessful attempts you will need to contact the IT help desk 517 780 3367 to obtain a reset Page 2 of 9 LifeWays Operating Procedures SECTION GOVERNING POLICY 7 00 Information Systems IS 01 IS Infrastructure Strategy and Management SUBJECT 03 Electronic Medical Record EMR Management EFFECTIVE DATE 03 01 2014 REVIEWED REVISED 11 01 2014 Physical Controls Users are responsible for maintaining the physical security of their workstation that is used to access the EMR and protected health information This includes immediately locking the device when not in use closing doors when away from the office where the device is located placing devices out of site when traveling e g truck of car password protecting the device for user authentication and being aware of the immediate surroundings and risks Minimum Necessary Rule Users are created with very specific access to areas in the EMR based on their position and function It is expected that the user access only the minimum information that is necessary to complete their job function The actions carried out by users in the EMR are logged and recorded This includes all attempts to read write and delete data LifeWays reserves the right to review the audit trails to determine if the access level is necessary and appropriate Audit t
36. eased externally and are not pending in the Document Disclosure Queue 24 CR No unsigned documents awaiting signature All documents are fully signed and not pending a staff signature 25 CR Consumer appointments are managed through updates to the appointment status Review consumer appointments and verify that the status of any past appointments has been changed from Scheduled to Kept Cancelled or No Show 26 DQ Address is complete and accurate Complete and accurate address define by valid Street City St Zip Home Phone 27 DQ Emergency contact information is present Emergency contact is provided or Section not applicable 28 DQ Primary guardian information is present Guardian is provided or Section not applicable 29 DQ Preferred pharmacy information is present Pharmacy is provided or Section not applicable 30 DQ Primary care physician information is present Physician is provided or Section not applicable 31 DQ Absence of critical data errors Consumer chart is free from all data quality errors LEO Quality and Integrity Standards for Electronic Medical Records LifeWays EMR Standards 3 Item Category Indicator Evaluation Criteria 32 FI A current self pay financial determination is complete verified by LifeWays Self pay is present and includes the consumer s signature that is obtained digitally or is scanned in as an attachment to the policy Supporting financial docume
37. ect 1 Minor Unlikely internal external customer s noticing the effect 2 Rate the occurrence O of the problem the number of times the problem or condition non conformance occurs during the defined process cycle within the scope of the element 5 Very High 80 or more of the time 4 High 60 79 3 Moderate 40 59 2 Low 20 39 1 Minor 0 19 3 Determine the number N of consumers and or customers affected The number of consumers and or internal external customers affected by the problem or condition non conformance during a defined period of time within the scope of the element 5 Very High 80 or more of consumers 4 High 60 79 3 Moderate 40 59 2 Low 20 39 1 Minor 0 19 LEO System Change Request Form LifeWays LEO System Change Request Form 2 Priority Ranking Score PRS S x O x N Design amp Planning Description of design and planned change Purpose of the change Attachments Screen layout Process diagram Instruction manual with business rules Screencasting video Prototype Testing amp Pilot Development System Effective Date Summary of input from testing and subsequent modifications Implementation amp Training Production System Effective Date Included in News Bulletin Training materials posted on website Sustainment Planned Evaluation Date Measures used to determine success Results of evaluation Reference
38. efine purpose Develop screen layout Develop process diagram Develop instructional manual and business rules Develop screencasting video or training LEO System Change Request Form LifeWays LEO System Change Request Form 1 Requested By Email Date of Request Identify Need amp Initiate System Concept Development A Describe the problem B Describe the recommended solution or concept C Define the scope or boundaries of the concept D Describe the impact expected outcomes and how success will be measured E Does this enhancement fit into the LifeWays mission and values Yes No F Does this enhancement fit into the LifeWays strategic plan Yes No G Does a lack of the enhancement inhibit quality service delivery to the consumer Yes No H Does the opportunity impact Mark all that apply Quality Productivity Safety Customer Satisfaction I Rating 1 Rate the severity S of the problem The seriousness of the problem or condition non conformance as it relates to the consumers and or the internal external customers 5 Very High Safety issue which poses potential harm to consumer and or internal external customers 4 High Ethical or quality issues that impacts service to internal external customer s 3 Moderate Probably has a noticeable effect on internal external customer s satisfaction 2 Low Slight chance of the internal external customer s noticing the eff
39. em please contact LifeWays Information Technology Director Click Add Consent to Exch Info to generate a new release LifeWays Community Mental Health Provider Manual EMR 29 13 CEHR PORTAL CONSUMER ACCESS TO MEDICAL RECORDS Providers should refer to LifeWays Consumer Access to Medical Records when a consumer wishes to have access to his or her medical record Link 6 03 02 Consumer Access to Medical Records LifeWays and PCE Systems would like to introduce a secure online portal for patients to access their own health information using the Internet The Community Electronic Health Record CEHR is now available Features include the ability to view diagnosis track medications vital signs allergies appointments contact information and other important components of their services Information available is from the LEO electronic medical record that behavioral health care providers use to document services through the LifeWays network Benefits of the patient portal is to inform the individual about their own health information and use this to work with their health care providers to manage their illness The long term goal is to use this portal as a way to interact with their health care provider and view treatment plan information Security of the information is protected and encrypted using an SSL certificate which meets the safeguards expected of Meaningful Use and HIPAA 14 BUSINESS CONTINUITY Each
40. erving the case Once the case is closed the provider and assigned staff will have limited view only access to the case through LEO for a period of 90 days The 90 day window after case closure is intended to provide the user with limited access to the case in order to complete final claims submission and clinical documentation activities After the 90 day period the system will automatically restrict access to the record and the user is forbidden from accessing the consumer s electronic medical record Page 3 of 9 LifeWays Operating Procedures SECTION GOVERNING POLICY 7 00 Information Systems IS 01 IS Infrastructure Strategy and Management SUBJECT 03 Electronic Medical Record EMR Management EFFECTIVE DATE 03 01 2014 REVIEWED REVISED 11 01 2014 INTEGRITY AND COMPLETENESS OF INFORMATION EMR Standards Professionals accessing the EMR shall consistently follow the standards established by the agency to achieve and maintain a high level of integrity and completeness of information within the EMR The agency has established a detailed set of Quality and Integrity Standards for Electronic Medical Records Attachment 1 Conformance to these standards is expected by all users Use of Electronic Forms LifeWays has created electronic forms within the EMR for primary chart documents These forms must be completed electronically within LEO and are no longer offered on paper It is expected that users fully utilize the electronic forms a
41. ess levels LifeWays reserves the right to modify user setup at any time if it is determined to be inappropriate Non compliance with the expectations as a Provider Administrator will result in revoke privileges and possible corrective action All system users are responsible for maintaining secure practices including 1 Privacy of passwords 2 Maintaining physical control of the equipment that is used to access the EMR and 3 Following the minimum necessary rule for accessing and disclosing protected health information Secure Passwords Passwords security is critical to the protection of information in the EMR Users have a primary role to minimize the risk of improper disclosure by using the following required secure password practices 1 Keep password secure and confidential to all others 2 Create strong passwords using alpha numeric and special characters 3 Change the password completely when prompted by the system or if security has been compromised 4 Lock the computer workstation when stepping away from your device every time This can be done by using Ctrl Alt Delete and then selecting Lock this Computer 5 Do not share password with others 6 Do not write down the password 7 Do not allow others to log in as you 8 Do not allow other people to watch you key your password in 9 Do not save your password in your internet browser Passwords are set to expire every 90 days in the EMR If you forgot your password you may us
42. feWays systems which are owned and operated by LifeWays and which are housed in the Server room are backed up daily Incremental backups are performed Sunday through Friday at 10 00 p m and take approximately 2 hours Full backups are performed on Saturdays at 10 00 p m and take approximately 8 hours Different backup schedules can be set up for particular machines by arrangement but IT staff would not normally run backups during prime shift hours i e between 8 00 a m and 6 00 p m on weekdays The Shadow Copy Service is also used which takes a snapshot of the data at 7 00 a m 12 30 p m and 6 00 p m daily This provides the ability to restore a file immediately without having to use backup media Files can only be restored to the state they were in at the time the most recent relevant backup shadow copy was taken though users may request restores from earlier backups if they wish Page 2 of 4 LifeWays Operating Procedures SECTION GOVERNING POLICY 7 00 Information Systems IS 02 IS Security and Risk Management SUBJECT 01 Business Continuity and Disaster Recovery EFFECTIVE DATE 08 21 2002 REVIEWED REVISED 03 01 2014 4 Telephone Management Currently at LifeWays there is one phone system in use The system is a Cisco Unified Communications System running on two Cisco Call Managers In the event that Call Manager 1 goes down Call Manager 2 has the ability to continue carrying out the last programming functions given to
43. formation Systems IS 01 IS Infrastructure Strategy and Management SUBJECT 03 Electronic Medical Record EMR Management EFFECTIVE DATE 03 01 2014 REVIEWED REVISED 11 01 2014 7 01 03 ELECTRONIC MEDICAL RECORD EMR MANAGEMENT PURPOSE The purpose of this operating procedure is to establish a management process for the electronic medical record that defines access and permissions system integrity and record completeness standards training and technical assistance efforts system change control process and communication plans Management of the EMR requires decision making planning and quality improvement throughout its life cycle The EMR is a mission critical function that supports the provision of care across the entire provider network system As a result procedures must be in place to support the integrity and accuracy of the information and components in order to achieve the highest effectiveness from the product It is also imperative that users of the product follow strict access confidentiality and security practices to provide for acceptable use and security of the protected health information maintained by the system SYSTEM COMPATIBILITY The LEO system is hosted developed and maintained by PCE Systems The LEO applicable is available in three environments 1 production 2 training and 3 development The production environment is the live setting that users use for electronic health record documentation The training envir
44. gin and passwords at all levels of access From a desktop a user must provider authentication to the network The user is then required to enter a password to use specific applications Some applications are limited by user license In the electronic medical record the user is required to have a need to know and access level is managed by a systems administrator Other security policies employed Network passwords are required to be a strong password includes letters number upper case and lower case characters and are set to automatically expire every 90 days Passwords must contain a minimum of 5 characters Old passwords can only be reused after a minimum of 3 expiration cycles Users are locked out after 4 unsuccessful attempts and IT Help Desk must clear locks and Access to shared resources is granted on a needs basis determined by IT Director and Chief Executive Officer Page 1 of 4 LifeWays Operating Procedures SECTION GOVERNING POLICY 7 00 Information Systems IS 02 IS Security and Risk Management SUBJECT 01 Business Continuity and Disaster Recovery EFFECTIVE DATE 08 21 2002 REVIEWED REVISED 03 01 2014 2 Power Management The local area network LAN in the Jackson LifeWays office gets its power from a series of uninterrupted power supply UPS which is powered from power supplied by Consumers Energy In the event of a power loss the UPS will keep the servers alive for up to 2
45. ions Intake Assessments User Manual Treatment Plans User Manual Service Activity Logs User Manual Page 8 of 9 LifeWays Operating Procedures SECTION GOVERNING POLICY 7 00 Information Systems IS 01 IS Infrastructure Strategy and Management SUBJECT 03 Electronic Medical Record EMR Management EFFECTIVE DATE 03 01 2014 REVIEWED REVISED 11 01 2014 Provider Claims User Manual Provider Management User Manual Calendar User Manual Case Load User Manual Sentinel Events User Manual Death Report User Manual Court Orders User Manual Integrated Health Assessment User Manual Consent to Exchange Information User Manual Progress Notes User Manual Medication Review Process Incident Report Manual HISTORY Effective 03 01 2014 Rev 7 14 9 14 Page 9 of 9 LEO Quality and Integrity Standards for Electronic Medical Records LifeWays EMR Standards 1 Effective 8 1 2013 Purpose The following table identifies the minimal standards necessary to determine an electronic medical record as complete and accurate Reference LifeWays Operating Procedure 07 01 03 Electronic Medical Record Management Item Category Indicator Evaluation Criteria 1 AD A staff assignment exists for each provider assignment There is at least 1 staff assignment under each provider assignment 2 AD Discharge pending approval is less than 14 days since author signature or is absent Discharges present and pending UM appro
46. ity and proper utilization of the EMR TRAINING AND TECHNICAL ASSISTANCE Page 5 of 9 LifeWays Operating Procedures SECTION GOVERNING POLICY 7 00 Information Systems IS 01 IS Infrastructure Strategy and Management SUBJECT 03 Electronic Medical Record EMR Management EFFECTIVE DATE 03 01 2014 REVIEWED REVISED 11 01 2014 Training The agency maintains the responsibility to provide training and education to users to support competency system integrity security and compliance with the EMR standards Training can be conducted through various methods including live instruction e learning modules written instructions with screen layouts videos with screencasting etc The trainer of the content shall be a subject matter expert LifeWays may user a peer or skilled training within a provider or program to transfer knowledge Training needs shall be evaluated through an annual survey process Requests for training can be made through the IT help desk at any time The IT team will coordinate a training to occur with the subject matter experts LifeWays may request a corrective action plan if after adequate training and technical assistance has been provided to the user non compliance with EMR standards and expectations remains The Quality Improvement amp Technology Division shall engage the Contract Management Team in any corrective action processes related to the EMR standards and expectations Resources The agency shall supply
47. ls in the record I understand and accept that I may not remove change or destroy any materials in the record I may submit additional information for the record which may correct information contained in the case record or which may express views that differ from those expressed in materials contained in the case record I am requesting to receive a copy of any all information in the case record Specific information requested if any is I would like to receive this information in _____ _____ Paper Form Encrypted Password Protected Flash Drive I understand and accept there may be a charge for the cost of materials for receiving the information requested I will be informed of the amount prior to processing I understand and accept that the Agency is the holder of the record and may under the authority of State law withhold information which it determines to be detrimental to the recipient or to other persons Michigan Mental Health Code Section 330 1748 5 b I understand that upon possession I take full responsibility for the protection and confidentiality of the information provided Date Signature LW 200 LW 60402 A 11 2014 This page is to be completed by supervisor I have verified that the above listed individual is authorized to receive the information requested above An appointment has been scheduled for review release on Date I have reviewed the information requested above and have recommend the following information no
48. mer is enrolled in school K 12 there is consent to release information to the school present Consents to exchange release info to the child s school is completed electronically or scanned into the record and is current 17 CR If consumer reports a primary care physician consent to release information to the physician is present Consents to exchange release info to the physician is completed electronically or scanned into the record and is current 18 CR Diagnosis Axis are complete Axis 1 5 The full diagnosis table is complete including Axis I II III IV and V 19 CR Advanced Directive status is collected and scanned into the chart is active Review the most recent consent to participate If the consumer indicates that they have an active advanced directive a copy is scanned into the consumer chart 20 CR Scanned documents are appropriately categorized and organized Review each scanned document that was entered during the current treatment plan and verify that the Document Type appropriately matches the content of the scanned image The date of the document should match the date within the document and not the date it was scanned There should be no duplication of scanned documents 21 CR Care coordination communication form is used and scanned into LEO in accordance with consents to release info i e beginning services medication changes hospitalizations discharges Care coordination is e
49. n statement to the Individual of the reasons for any delay and the date by which LifeWays will complete its response to the request which shall not be later than thirty 30 calendar days after delivery of the notice of delay In the event that the PHI requested does not exist or cannot be found and produced within sixty 60 calendar days after receipt of the initial request LifeWays shall inform the Individual that the PHI cannot be produced d If the requested PHI is not maintained or accessible to LifeWays on site LifeWays shall either produce the PHI or provide a written denial no later than sixty 60 calendar days from the receipt of the initial request If LifeWays is unable to take such action within sixty 60 calendar days of the receipt of the request then LifeWays shall provide a written statement to the Individual of the reasons for any delay and the date by which LifeWays will complete its response to the request which shall not be later than thirty 30 calendar days after delivery of the notice of delay e Only one extension of time for action will be allowed for each request made by an Individual 2 Access of Protected Health Information Provided If a LifeWays entity provides an Individual with access in whole or in part to PHI the following will be required a The individual must request access to inspect and or copy PHI in writing b LifeWays must provide the access of PHI requested by Individuals including inspection
50. nagement SUBJECT 06 Uses and Disclosures of Protected Health Information EFFECTIVE DATE 03 10 2010 REVIEWED REVISED 1 A LifeWays department that generates confidential information with regard to consumers is responsible to maintain the materials in a confidential manner 2 At the appropriate time in accordance with Michigan s Records Retention law the department in which the materials are generated and stored may elect to shred the materials utilizing one of LifeWays standard document shredders 3 Certain departments may generate highly sensitive documents in large volumes necessitating purchased contract services for material destruction i e materials coming out of document retention 4 Documents stored in file boxes shall be appropriately labeled with Contents type and date designated for destruction based on the Records Retention Law REFERENCES U S Health Insurance Portability and Accountability Act of 1996 HIPAA LifeWays Privacy Notice LifeWays Policy 01 06 Record Retention and Disposal 06 04 Medical Record Management LifeWays Operating Procedures 07 05 06 Electronic Mail Guidelines and Requirements 06 04 01 Medical Record Release of Information 06 04 02 Provider Access to Closed Records 06 04 03 Retention amp Disposal of Medical Records 06 04 04 Transfer of Consumer Files 06 04 05 Denial of Consumer Requests HISTORY Effective 03 10 2014 Rev Page 3 of 3 LifeWays Operating Procedure
51. nal has determined in the exercise of professional judgment that the access requested is reasonably likely to cause substantial harm to such other person or c The request for access is made by the individual s legally authorized representative and a licensed health care professional has determined in the exercise of professional judgment that the provision of access to such representative is reasonably likely to cause substantial harm to the individual or another person LifeWays Operating Procedures CHAPTER GOVERNING POLICY 6 00 Customer Services 03 Medical Record Management SUBJECT 02 Consumer Access to Medical Records EFFECTIVE DATE 12 01 2013 REVIEWED REVISED 11 01 2014 Page 5 of 5 If access is denied by one of these grounds the individual has the right to have the denial reviewed by a licensed health care professional who is designated by LifeWays to act as a reviewing official and who did not participate in the original decision to deny 6 Documentation All release requests and completed releases shall be documented within LEO through the Document Disclosure log a Date released b Scanned Application c Brief description of what was actually released to the individual d Purpose for the release e Information regarding the denial of access f LifeWays Personnel facilitating the release 7 In accordance with the Medical Records Access Act 47 of 2004 333 26269 Section 9 LifeWays has established
52. nce reports abuse reports B Internal Confidential Information 1 Proprietary information 2 Financial records and reports 3 Business transaction records C Protected Health Information 1 Names 2 All geographical identifiers smaller than a state except for the initial three digits of a zip code if according to the current publicly available data from the Bureau of the Census the geographic unit formed by combining all zip codes with the same three initial digits contains more than 20 000 people and the initial three digits of a zip code for all such geographic units containing 20 000 or fewer people is changed to 000 3 Dates other than year directly related to an individual Page 1 of 3 LifeWays Operating Procedures SECTION GOVERNING POLICY 7 00 Information Technology 02 Information Security and Risk Management SUBJECT 06 Uses and Disclosures of Protected Health Information EFFECTIVE DATE 03 10 2010 REVIEWED REVISED 4 Phone numbers 5 Fax numbers 6 Email addresses 7 Social Security numbers 8 Medical record numbers 9 Health insurance beneficiary numbers 10 Account numbers 11 Certificate license numbers 12 Vehicle identifiers and serial numbers including license plate numbers 13 Device identifiers and serial numbers 14 Web Uniform Resource Locators URLs 15 Internet Protocol IP address numbers 16 Biometric identifiers including finger re
53. nformation_____ This denial applies to a portion of the information you requested The portion of your request denied is the ______________________ Determine which paragraph is needed depending on the reason for denial You have the right to have this decision reviewed by licensed health care professionals not directly involved in our initial decision to deny your request If you want to exercise this right please contact the LifeWays Customer Service Department at 866 630 3690 We will comply with the health care professionals decision Determine which paragraph is needed depending on the reason for denial Due to the reason cited for denial the federal law does not allow the right to have this decision reviewed If you believe we have improperly handled your request to access your protected health information you may file a complaint with us or with the Secretary of the United States Department of Health and Human Services To file a complaint with us please contact the LifeWays Customer Service Department at 866 630 3690 Please be assured no one will retaliate or take action against you for filing a complaint Thank you Elizabeth Knoblauch Director of Strategic Relations LifeWays Operating Procedures SECTION GOVERNING POLICY 7 00 Information Systems IS 02 IS Security and Risk Management SUBJECT 01 Business Continuity and Disaster Recovery EFFECTIVE DATE 08 21 2002 REVIEWED REVISED 03 01 2014 07 02 01 BUSINESS CONT
54. nity Mental Health Provider Manual EMR 25 Submit a ticket through the Help Desk module within LEO for non urgent issues The LEO Help Desk can be accessed while in LEO from the menu of items listed in the green box of the home page Step 4 is submitting the required information needed regarding your issue and clicking save For additional detailed instructions for submitting a Help Desk ticket please refer to the attachment below Contact the LEO Help Desk at 517 780 3367 internal x2367 for urgent issues Step 1 Step 2 Step 3 LifeWays Community Mental Health Provider Manual EMR 26 Urgent is defined as something that impacts the provider s ability to move forward and complete their essential function LifeWays also maintains a LEO Help Desk Directory If you have a specific subject matter that you need assistance with please contact the following SUBJECT MATTER CONTACT PERSON Contracts Fee Schedules Codes Modifiers Rates Provider Records COFRs Single Case Agreements Contract Manager 517 880 3353 Incident Reports Recipient Rights Administrative Assistant 517 789 1237 Insurance Policies Medicaid Look Up Financial Information Ability to Pay Medicaid Application Networks Benefits Specialist 517 789 2497 Claims Processing Remittance Advice Claims Specialist 517 796 4586 Password Resets Staff Records Assigning User IDs Provider Administrator User Access Initial Menu View Spell Check
55. ntation is scanned in as an attachment to the policy 33 FI Insurance policies are verified All insurance policies for the case are Verified and not in Awaiting Verification status 34 FI Medicaid deductible policy is present if the consumer is on a deductible If the consumer is on a Medicaid deductible there is a Deductible policy entered in the insurance policy area and it is not expired until the deductible no longer applies 36 IR Incident Reports are routed for signature and reviewed signed in a timely matter Search IR module for all incident reports for the consumer and verify that they have been fully reviewed by all Reviewers as indicated by a Review Date next to each reviewer The Review Date should not be null 37 MC Medication consents are present and include consumer and medical staff signature for all current medications Review the most recent Medication Review to determine the medications that are active then review the Signed Medication Consents in the Medical Chart to determine if there s a signed consent for each active medication 38 MC AIMS worksheet is completed quarterly for psychotropic medications Review CMH Medications to determine if Psychotropic medications have been prescribed and evaluate if AIMS testing has been completed every three months since the effective date of the prescription 39 MC Allergies adverse reactions have been completed in last 12 months Adverse rea
56. octor there is no charge Otherwise the charge for copying is 20 per page Payment must be received before the information can be given out Send a letter to the person agency requesting the information Attachment A and file in the folder entitled Payment Required Send a copy of the letter to the Finance Team The Payment Required folder may be purged every ninety 90 days Information which may be copied from the medical record includes Initial Intake Protocol found under the Clinical Assess Non Medical tab Treatment Plan during the past year found under the Clinical Treatment tab Treatment Plan Individual Plan of Service Annual Psychiatric Assessments up to the last two found under the Progress Notes Incidents tab Treatment section Physician Unit files only It is usually indicated by a colored 3M tab Initial is purple annual is yellow and all others are red Medication Reviews during the past year found under the Progress Notes Incidents tab It is usually indicated by a red 3M tab Page 1 of 3 LifeWays Operating Procedures CHAPTER GOVERNING POLICY 6 00 Consumer Services 03 Medical Record Management SUBJECT 01 Medical Record Release of Information EFFECTIVE DATE 09 30 1997 REVIEWED REVISED 04 12 2012 Additional information must be approved by the Clinical Director The information is copied and then mailed with the following A copy of the Consent to Release Informa
57. on 38 MC AIMS worksheet is completed quarterly for psychotropic medications Review CMH Medications to determine if Psychotropic medications have been prescribed and evaluate if AIMS testing has been completed every three months since the effective date of the prescription 39 MC Allergies adverse reactions have been completed in last 12 months Adverse reaction allergies have been recorded within the last 12 months If no allergies this is accurately recorded as NKDA No Know Drug Allergies as the Drug Allergen 40 MC Dispense notes are present for injectable medications If consumer is prescribed an Injectable Medication dispense notes are present to record the dispensing at the frequency noted within the prescription 41 MC Lab results are scanned or electronically transmitted results are reviewed by ordering physician If consumer has a Lab Order in LEO there is a corresponding Lab Result that has been reviewed by the ordering physician 42 MC CMH medications are present and current and align with the most recent medication review note Review last medication review and cross walk with the CMH prescribed medications for accuracy and completeness 43 MC No lab results awaiting review There are no lab results for the case that are Pending Review in the medical chart 44 MC Non CMH medications are present and current consumer self reports Review last medication review and cross walk wi
58. onment is a duplicate of production to use for training purposes changes within training will not harm the production system The development environment is used to create and test new system changes before they are moved to production Internet Explorer The LEO application is programmed to be compatible with Internet Explorer IE There are specific functions and forms that are not fully operable unless used in Internet Explorer Therefore the agency requires that Internet Explorer is used as the web browser to run the LEO system The most recent version of Internet Explorer should always be used as PCE Systems works diligently to maintain compatibility with the newest IE release ACCESS AND PERMISSIONS Expected Use LifeWays staff and contracted service providers are expected to fully implement the LEO system within their workflow to document services rendered Staff of programs or providers that are authorized to serve a LifeWays consumer is expected to document care using all appropriate modules and forms that have been made available and within their scope of care This requirement is to ensure complete and accurate service documentation and facilitate effective care coordination amongst mutually serving program and providers within the LifeWays CMH system There are no exclusions to the requirement to use the LEO system unless a user can demonstrate that it creates a significant hardship and this has been reported to and approved by the Director of
59. provider is encouraged to have on hand at all times paper forms in the event LEO is down during regular business hours If an outage is anticipated i e inclement weather the minimum amount of information needed to continue services should be printed and available to staff These items may include schedules last appointment notes consumer contact information etc Each provider is responsible for the security of these records and should shred them once power is restored Link 7 02 01 Business Continuity and Disaster Recovery 15 TRANSITION TO ICD 10 AND DSM 5 TRANSITION TO ICD 10 ICD 10 implementation has been delayed by one year per recent legislation The implementation is now effective 10 1 2015 Expected Future Changes We will continue with Phase 1 B2B testing and collecting the ICD 10 diagnosis We can still shift to Phase 2 on 10 1 14 ICD 10 becomes the primary diagnosis and ICD 9 is housed in the system as backup and for encounter claims reporting next year Phase 3 would begin next October phase out of ICD 9 and only use it for claims with date of service 10 1 15 LifeWays is joining a PCE workgroup and continuing participation on the TSG state workgroup to follow and implement changes LifeWays Community Mental Health Provider Manual EMR 30 Providers and LifeWays staff should continue to seek out clinical training opportunities for ICD 10 TRANSITION TO DSM 5 It is important to
60. racted providers are responsible for establishing a process for dealing with Consumer access to health information in compliance with this policy LifeWays contracted providers are prohibited to release any documentation not authored by their paid staff LifeWays Community Mental Health as the owner of the record in its entirety has authority to access and release any and all pieces of record with exception as defined by the HIPAA and LifeWays Procedure Items not privy for release shall not be included in the LifeWays electronic medical record LEO i e psychotherapy notes 1 Requests for Access and Timely Action LifeWays shall permit an individual to request in writing access to inspect and or to obtain a copy of an consumer s PHI that is maintained in a designated record set a Upon receipt of a request LifeWays shall make reasonable efforts to verify the identity of the person making the request and determine whether such person is an Individual LifeWays shall not inquire as to the purpose of any request b LifeWays shall make its best efforts to act whether granting or denying the request by providing the Individual with a written response within fifteen 15 calendar days after receipt of the written request for access or inspection c Notwithstanding the foregoing in the event that LifeWays is unable to provide a response to a request within thirty 30 calendar days after receipt of the request LifeWays shall provide a writte
61. rail reports are available to LifeWays System Administrators on the IT team The agency retains the right to terminate any user access at any time ACCESS TO CASE RECORDS Users are granted access to case records in LEO based on their affiliation with a service location LifeWays or the designated Provider Administrator is responsible for assigning the user to a location and grating functional access Location assignments must be done with great care and caution Users shall not be assigned to locations in which they are not employed Once assigned to a specific location by LifeWays or the Provider Administrator the user will have access to the consumer records that are also assigned to that location Case records within the assigned location must be accessed on a need to know basis Simply having access to the file does not grant the user rights to review protected health information Terminated Access It is expected that users complete a discharge summary immediately when it is known that their organization program will no longer serve the case a discharge summary will close out the access level The IT team may request a discharge summary from the provider to properly close from the case LifeWays reserves the right to conduct an administrative closure of agencies or users to remove access to a case record when there is a period of inactivity The purpose is to minimize case access to only users that are authorized for service delivery and are activity s
62. s CHAPTER GOVERNING POLICY 6 00 Consumer Services 03 Medical Record Management SUBJECT 01 Medical Record Release of Information EFFECTIVE DATE 09 30 1997 REVIEWED REVISED 04 12 2012 6 03 01 MEDICAL RECORD RELEASE OF INFORMATION PURPOSE To release information for the purpose of coordination of care to receive SSI benefits legal purposes etc All requests for Medical Release of Information received by LifeWays are forwarded to Customer Services The CSS Customer Services Specialist reviews each release Releases typically fall into one of the categories below Open Consumer file located at provider site Valid Request for Medical Records Closed file file located in Customer Services Invalid request for Medical Records Closed File No Record of Person in Computer System Following is the process for each category Open Consumer File Located at Provider Site Upon checking in the computer if it is an open case the request is forwarded to the consumer s primary provider The consumer s name company agency requesting the information and the primary provider is logged in the Release of Information Requests binder before the release is forwarded Valid Request for Medical Records Closed File Requests should be processed within five 5 working days from date stamped by LifeWays Copying Charge if the request is to assist in coordination of care such as a hospital social security or d
63. s LifeWays Operating Procedure 07 01 03 Electronic Medical Record Management LEO System Change Request Form LifeWays LEO System Change Request Form 1 Requested By Email Date of Request Identify Need amp Initiate System Concept Development A Describe the problem B Describe the recommended solution or concept C Define the scope or boundaries of the concept D Describe the impact expected outcomes and how success will be measured E Does this enhancement fit into the LifeWays mission and values Yes No F Does this enhancement fit into the LifeWays strategic plan Yes No G Does a lack of the enhancement inhibit quality service delivery to the consumer Yes No H Does the opportunity impact Mark all that apply Quality Productivity Safety Customer Satisfaction I Rating 1 Rate the severity S of the problem The seriousness of the problem or condition non conformance as it relates to the consumers and or the internal external customers 5 Very High Safety issue which poses potential harm to consumer and or internal external customers 4 High Ethical or quality issues that impacts service to internal external customer s 3 Moderate Probably has a noticeable effect on internal external customer s satisfaction 2 Low Slight chance of the internal external customer s noticing the effect 1 Minor Unlikely internal external customer s noticing the effect 2 Rate
64. s appropriate to their scope and practice A scanned document of a paper form is unacceptable if an electronic form has been made available The following is a list of the standardized clinical forms that are required for providers and programs of LifeWays Access Screening Crisis Intervention Clubhouse Progress Note Weekly Death Report Discharge Summary Financial Determination Group Progress Note Incident Report Injection Dispense Note Intake Update Assessment Integrated Health Assessment Medication Delivery Progress Note Medication Review Pre Planning Progress Note Psychiatric Evaluation Residential Quality of Life Assessment for services providing in a residential setting Supported Employment Progress Note Treatment Plan amp Crisis Plan Treatment Plan Addendum Treatment Plan Formal Review The following is a list of the optional electronic forms that are available within LEO to providers programs of LifeWays It is understood that programs may utilize this form or their own Page 4 of 9 LifeWays Operating Procedures SECTION GOVERNING POLICY 7 00 Information Systems IS 01 IS Infrastructure Strategy and Management SUBJECT 03 Electronic Medical Record EMR Management EFFECTIVE DATE 03 01 2014 REVIEWED REVISED 11 01 2014 forms until a standard consent is created for the entire CMH network At that time the LEO
65. scanned in as an Attachment to the Treatment plan Consumer s signature can be found within the Treatment Plan print or as a scanned document within the Attachments 51 TP Copy of treatment plan is provided to consumer Treatment plan shell header displays the date and method in which the copy of plan was provided 52 TP Notice of Hearing Rights is signed by consumer and scanned in as an Attachment to the Treatment plan including subsequent Addendums Signed paper notice is scanned is as an Attachment to the treatment plan or plan addendum 53 TP Treatment plan formal review has occurred quarterly since treatment plan effective date A formal review was completed every 3 months using the electronic form since the treatment plan effective date 54 TP Treatment plan is fully signed by provider staff Treatment plan is entered electronically not scanned and is not pending staff signature End SUD SUD T1 T2 Field Name A M M w Int Tx D E E MH w Int Tx U MH U MH w Int Tx A001 DU001 Client Transaction Type A M M D E E U U F MDS Coding Keys A002 DU002 System Transaction Type A M M D E E U U F SDS MH amp SUD NOM A003 DU003 Payer ID A M M D E E U U S MH NOM A004 DU004 State Provider Identifier A M M D E E U U F MDS SUD NOM A005 DU005 Unique PIHP Person Identifier A M M D E E U U F MDS A006 DU006 Social
66. ss days from the date of service Document Deletion The agency maintains a position that the documentation in the EMR system must be of high integrity Therefore documents entered in the LEO system are considered part of a permanent record and shall not be deleted The only exception to this standard is documentation that is done in error e g wrong chart duplication If a document has been entered in error the user shall report this to their Supervisor for deletion If the Supervisor does not have permissions to delete that specific type of document the request for deletion shall be reported to the LifeWays IT Help Desk by the user s supervisor with a written request to delete using the Help Desk module to enter a ticket which signifies the supervisor s approval of the document deletion A LifeWays System Administrator IT Staff retains all rights to deleting documentation and will only execute this task when written confirmation from the requestor s supervisor has been received and it is determined to be done in error If there are identified patterns at the user level regarding the volume and frequency of requests to delete documents the agency reserves the right to remove the user s access to the EMR and request a training plan LifeWays shall evaluate compliance with these standards through periodic desk audits The auditing results shall be used for corrective action and continuous quality improvement in an effort to support the integr
67. sures Input is received from primary end users to determine success COMMUNICATION The agency shall follow the change control process for system enhancements in order to effectively communicate with system users Changes are communicated primarily through the LEO News Bulletin which is published on the LifeWays website and emailed to the EMR List Serv managed in Constant Contact The Bulletin shall describe the purpose description of the change and effective date The agency shall release the Bulletin as official notice of a scheduled change Changes will usually occur on the first day of the following month Primary users shall be provided with the opportunity to test the change in the Development system and provide input before it is in the Production system Bulletins will be archived on the LifeWays website for future reference and instruction The agency will use the LifeWays Provider Meeting as a mechanism to communicate critical changes to the system provide training and seek input REFERENCES U S Health Insurance Portability and Accountability Act of 1996 HIPAA U S Health Information Technology for Economic and Clinical Health Act of the American Recovery and Reinvestment Act of 2009 LifeWays Operating Procedures 07 01 01 Data Validation and Management Page 7 of 9 LifeWays Operating Procedures SECTION GOVERNING POLICY 7 00 Information Systems IS 01 IS Infrastructure Strategy and Management SUBJECT 03 Electronic Medi
68. t be disclosed For the following reason Non Reviewable ___ The request is for psychotherapy notes ___ Information compiled in reasonable anticipation of or for use in a civil criminal or administrative action or proceeding ___ An inmate s request to obtain a copy of PHI if obtaining such copy would i jeopardize the health safety security custody or rehabilitation of the individual or of other inmates or ii jeopardize the safety of any officer employee or other person at the correctional institution or responsible for the transporting of the inmate ___ Protected health information contained in records that are subject to the Privacy Act 5 U S C 552a may be denied if the denial of access under the Privacy Act would meet the requirements of that law or ___ The protected health information was obtained from someone other than a health care provider under a promise of confidentiality and the access requested would be reasonably likely to reveal the source of the information Reviewable ___ A licensed health care professional has determined in the exercise of professional judgment that the access is reasonably likely to endanger the life or physical safety of the individual or another person ___ The PHI makes reference to another person unless such other person is a health care provider and a licensed health care professional has determined in the exercise of professional judgment that the access requested is reasonabl
69. th the non CMH prescribed medications for accuracy and completeness 45 MC Initial Psychiatric Evaluation is present A psychiatric evaluation is present 46 MC No verbal orders awaiting review There are no verbal orders awaiting the physician s approval for the case 47 MC Vital signs have been completed in last 12 If authorization for medication review or psychiatric LEO Quality and Integrity Standards for Electronic Medical Records LifeWays EMR Standards 4 Item Category Indicator Evaluation Criteria months for consumers receiving Psychiatric services evaluation is present there are vital signs recorded within the last 12 months 48 PG Progress notes are present for all active providers Review authorized providers and cross reference with the progress note module A progress note should be present for all active authorized providers The progress notes should be entered electronically if a e format for the note is available otherwise a scanned progress note is accepted 49 TP Residential quality of life assessment was completed by residential staff prior to PCP meeting If consumer has specialized residential services verify in demos and the treatment plan shell header there is a residential quality of life assessment included in the treatment plan and it was completed by the residential staff before the date of the PCP meeting 50 TP Consumer signatures are obtained digitally or
70. the following fee structure for complying with requests LifeWays staff may use discretion when applying costs The individuals shall be made aware of costs prior to duplication Paper copies Initial fee of 20 00 per request for a copy of the record One dollar per page for the first 20 pages Fifty cents per page for pages 21 through 50 Twenty cents for pages 51 and over For digital duplication onto a password protected encrypted flash drive 35 00 Postage or shipping costs Actual costs incurred for records older than seven years REFERENCES 45 CFR 164 524 Attachments Application for Access to Recipient Case Record Information LW 60302 A Request for Access to Medical Records Notice of Denial LW 60302 B HISTORY Effective 12 01 2013 Rev LW 200 LW 60402 A 11 2014 APPLICATION FOR ACCESS TO RECIPIENT CASE RECORD INFORMATION I hereby request access to information from the case record of and or Name of Recipient Date of Birth Social Security Number My relationship to the recipient is check one Recipient Parent Guardian Address Telephone Documentation of the relationship to the recipient and personal information may be required prior to disclosure of the information requested I am requesting an appointment to review any all information in the case record I understand and accept that the supervisor and or his her designee will be present when I am reviewing the materia
71. tinal and voice prints 17 Full face photographic images and any comparable images 18 Any other unique identifying number characteristic or code except the unique code assigned by the investigator to code the data POLICY It is the policy of LifeWays to protect the privacy and confidentiality of all consumer medical records and information contained in the medical records including the consumer s Protected Health Information PHI in accordance with applicable state and federal laws and ethical standards LifeWays prohibits persons not authorized by law to obtain access to or copies of a consumer s PHI and medical records LifeWays will provide a consumer access to and the right to obtain copy of his or her PHI in the medical record as long as it is maintained in the medical record and in accordance with this procedure Medical records of LifeWays consumers which are maintained by LifeWays and its provider network recorded in any form including data recorded on paper scanned images in a computer database or any other medium constitute the property of LifeWays LifeWays prohibits the removal of any original medical records from LifeWays premises or electronic medical records unless the records are ordered by a court of law or other government authority to be produced in the original form PROCEDURE Page 2 of 3 LifeWays Operating Procedures SECTION GOVERNING POLICY 7 00 Information Technology 02 Information Security and Risk Ma
72. tion form Attachment C the copied records and a cover letter Attachment A Complete Form 1023 the Documentation of Released Information Attachment B and staple to the original request and a copy of the cover letter File in the section entitled Consent and Authorizations of the medical record The consumer s name company agency requesting the information and the date the information is logged in the Release of Information Requests binder Invalid Request for Medical Records Closed File Invalid request are those not meeting the criteria set in the Michigan Mental Health Code 330 1748 permitting releases as referenced in this section Return the request with a cover letter Attachment D to the sender with a copy of Form 1009 Consent for the Mutual Release of Confidential Information Attachment C Once valid release is received the release of information request will be processed No Record of Person In Computer System Return the request with a Cover Letter to the Sender Attachment E indicating there is no record of the person Log the information on the No Record of Person Log in Release of Information Request binder It is not necessary to retain a copy of the request or letter Subpoenas for Information in Closed Records All subpoenas are forwarded to the Recipient Rights Team Leader and reviewed on a case by case basis Following is the process which usually occurs Within two 2 working days the Recipient Rights Team
73. val are less than 14 days old 3 AD Open provider assignment has active authorization to serve the case There is a provider assignment for each authorized provider Providers without active authorizations have been closed 4 AD Primary case holder is assigned for open case Open case has active primary case holder staff assigned 5 AD Primary provider is assigned for open case Open case has active primary provider assigned 6 AS If behavior treatment plan exists BRMC case notes are present according to BTP review schedule Review the BTP for the indicated BRMC review schedule The BRMC case review notes should be completed according to the specified BRMC review schedule 7 AS BRMC Case Review form is completed prior to discharge summary If discharge needs BRMC review the BRMC case review form is less than the discharge form date 8 AS If child CAFAS PECFAS assessment has occurred in last three months If the consumer is age 7 17 a CAFAS score is present If consumer is age 4 6 a PECFAS score is present Score should be recently entered in the last 3 months 9 AS DD proxy measures have been completed in last 12 months If consumer has a DD disability designation there is a DD proxy measure entered in the last 12 months 10 AS Assessment has occurred in last 12 months An intake or update assessment was completed within the last 12 months for open case 11 AS Health conditions
74. various learning materials such as written instructions how to guides FAQs tutorials or other forms of educational content that can be made readily accessible and utilized by the end user when technical assistance or troubleshooting is needed Help Desk If the user is unable to self resolve the issue the user shall contact the LEO Help Desk by calling 517 780 3367 internal x2367 or submitting a ticket through the Help Desk module within LEO The LEO Help Desk is intended to provide technical assistance and troubleshooting of system errors for traditional business operations that currently exist within the EMR The agency shall maintain high standards for timeliness of response and resolution and maintain open communication with the user regarding attempts made to resolve the help desk ticket The LEO Help Desk is not designed to field system enhancements or suggestions from end users Enhancements or suggestions for system improvement and modification shall follow a separate and formal change control process SYSTEM CHANGE CONTROL PROCESS It is expected that the system will evolve and changes will be necessary as areas for improvement are identified The agency shall maintain an organized process for receiving and implementing system enhancements The following change control process will be followed for EMR system changes Phase Description of Systems Development Life Cycle 1 Initiation Begins when a user identifies a need or an opportunity
75. vident by a health care coordination form document in the record 22 CR If guardian is present there is guardianship papers are on file If a guardian is indicated in the Consumer Information there are guardianship papers scanned into the consumer chart 23 CR No documents awaiting disclosure in the Medical Record queue The requested documents have been released externally and are not pending in the Document Disclosure Queue 24 CR No unsigned documents awaiting signature All documents are fully signed and not pending a staff signature 25 CR Consumer appointments are managed through updates to the appointment status Review consumer appointments and verify that the status of any past appointments has been changed from Scheduled to Kept Cancelled or No Show 26 DQ Address is complete and accurate Complete and accurate address define by valid Street City St Zip Home Phone 27 DQ Emergency contact information is present Emergency contact is provided or Section not applicable 28 DQ Primary guardian information is present Guardian is provided or Section not applicable 29 DQ Preferred pharmacy information is present Pharmacy is provided or Section not applicable 30 DQ Primary care physician information is present Physician is provided or Section not applicable 31 DQ Absence of critical data errors Consumer chart is free from all data quality errors LEO Quality and Integrity St
76. ward the telephone lines Call the AT amp T CLAR phone number at 517 483 9994 When prompted enter the following pin 99999999 When prompted enter the following plan 0 EVALUATION OF RESPONSE After the system has been restored the IT Department shall participate in a review of the effectiveness of its response and the ability to restore the information system infrastructure to original status This evaluation will include recommendations for improvement which will be reported to the Chief Executive Officer and Disaster Recovery Coordinator REFERENCES LifeWays Enterprise Risk Management amp Disaster Response Plan LifeWays Operating Procedures 7 02 02 Information Access and Systems Security 7 02 03 Data Backup and Restore 7 02 04 Data Archival Retention and Disposal HISTORY Formerly LifeWays Operating Procedure 07 03 01 Disaster Management Plan Effective 08 21 2002 Rev 10 03 07 05 08 09 Page 4 of 4
77. which access has been provided if the Individual agrees in advance to such a summary or explanation f Except as otherwise provided in Section 1 LifeWays must provide the access as requested by the Individual within thirty 30 days after receipt of the request including arranging with the Individual for a convenient time and place to inspect or obtain a copy of the PHI or mailing the copy of the PHI at the Individual s request LifeWays may discuss the scope format and other aspects of the request for access with the individual as necessary to facilitate the timely provision of access 3 Access of PHI Denied If LifeWays denies access in whole or in part to PHI LifeWays must comply with the following requirements a LifeWays must to the extent possible give the individual access to any other PHI requested after excluding the PHI that is being denied b LifeWays must provide written denial See Attachment A to the individual within thirty 30 calendar days following receipt of the request The denial must be in plain language and contain the following i The basis for the denial ii If applicable a statement of the individual s review rights including a description of how the individual may exercise such review rights and iii A description of how the individual may complain to LifeWays or to the Secretary of Health and Human Services The description must include the name or title and telephone number of the cont
78. y entered in the last 3 months 9 AS DD proxy measures have been completed in last 12 months If consumer has a DD disability designation there is a DD proxy measure entered in the last 12 months 10 AS Assessment has occurred in last 12 months An intake or update assessment was completed within the last 12 months for open case 11 AS Health conditions are complete A selection is present for every health condition listed in the health amp other conditions page 12 AS If consumer is authorized for a BTP there is a BTP scanned into LEO If consumer is authorized for H0032 BT there is a scanned BTP in the scanned document file 13 AS Psychiatric inpatient stays are managed through continued stay reviews and hospital discharge planning If psychiatric inpatient authorization is present there is a continued stay review and hospital discharge from 14 CR Chart Notes are used appropriately for miscellaneous documents or chart warnings If a chart note is present in the record it is for miscellaneous purposes and not billable documentation or information that is applicably stored elsewhere 15 CR Consent to participate is present Consents to participate for all active providers are LEO Quality and Integrity Standards for Electronic Medical Records LifeWays EMR Standards 2 Item Category Indicator Evaluation Criteria completed electronically or scanned into the record 16 CR If consu
79. y likely to cause substantial harm to such other person or ___The request for access is made by the individual s legally authorized representative and a licensed health care professional has determined in the exercise of professional judgment that the provision of access to such representative is reasonably likely to cause substantial harm to the individual or another person ____ Written denial has been provided to the requestor Date Authorized Personnel Signature Copy to Administrative File Recipient s File Recipient or Parent Guardian LW 60402 B 11 2014 REQUEST FOR ACCESS TO MEDICAL RECORDS NOTICE OF DENIAL August 3 2015 Patient Name Guardian Name If applicable Address Phone No Record No Date of Birth Date of Service Relationship to Patient Check one _____ Patient ______ Parent ______ Legally Authorized Representative Dear ______ This letter is in response to your request dated ______ to access your health information which we received from you on _____ This request has been reviewed by a licensed health care professional The health information is enclosed with this correspondence however a portion of your request has been denied Under federal law we are not required to provide the information in the event a licensed health care professional has determined in the exercise of professional judgment that the access is _____language taken from page 2 of Application for Access to Recipient Case Record I

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