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Sept. 11th and anthrax bring home one important message to all health care professionals, including HIM specialists: There is no possible way a department can prepare for every contingency.
It’s not like the old days of preparing for natural disasters such as fires, hurricanes, tornadoes, earthquakes, and floods. These days, a coding department could be shut down for hours or even a day or longer just by the appearance of an envelope coated in a powdery white substance. Likewise, after a hospital has been hit with a large influx of casualties after a terrorist attack, HIM professionals could find themselves taxed by people trying to locate missing loved ones and insurers trying to identify covered patients.
The good news is that HIM departments do not have to prepare for every possible disaster in order to effectively handle what comes along.
"The value of disaster planning isn’t necessarily that you anticipate the right disaster, but that you talk about it with your staff so that you know what resources are available so these can be applied to a disaster you didn’t think of," says Gwen Hughes, RHIA, a Belgrade, MT-based professional practice manager with the Chicago-based American Health Information Management Association (AHIMA).
Some disasters have internal and often unforeseen causes, adds Hughes, who has written articles and spoken to health care groups about disaster planning.
"Say a sprinkler system goes off and sprays everything," Hughes offers as an example. "Then the paper can get wet and be ruined, so you might have tarps in the department to throw over them."
Or if a hospital is flooded from the ground up, as happened last year in Houston, then an HIM department could save its paper documentation by putting boxes of files on stretchers that are borrowed from the emergency department, Hughes adds.
HIM disasters sometimes are caused by employee sabotage, says Jill Burrington-Brown, MS, RHIA, a Snohomish, WA-based professional practice manager with AHIMA. Burrington-Brown also has written about disaster planning and has studied the problems faced by Oklahoma City hospitals after the bombing of the Murrah federal building in 1995.
"I had a mini-disaster at one facility where over a six-month period a clerk whose night job was to file records had been putting files above the ceiling tiles in the department," Burrington-Brown says. "Within four months we knew we were missing a lot of records, but we couldn’t figure out where they were."
This caused a great deal of documentation problems when records were being requested and none of the hard copies could be found. Then when the department finally found the files during a heating system check, there was a second mini-disaster because now the staff had to cope with filing an additional 10,000 records and making them accessible as soon as possible, Burrington-Brown says.
"We made a plan of how to keep up the regular workload while having the records filed as fast as possible," Burrington-Brown adds.
That type of scenario proves that it’s impossible to anticipate every type of potential disaster, Hughes says.
"But the value is in going through the process and discussing things with the staff anyway," she explains. "Sure, if we anticipate employee sabotage, like someone who is angry getting into the payroll system, then as soon as we plan for it, the disaster will be something different."
Nonetheless, all HIM departments can take some basic disaster-planning precautions and follow strategies that will assist them in remaining flexible should an unforeseen disaster event occur. Here are some suggestions from Hughes and Burrington-Brown and from AHIMA:
• Know your liabilities and limits.
Under the Health Insurance Portability and Accountability Act (HIPAA), health care providers are required to maintain patient privacy. Breaches in an HIM department’s electronic records and the unintended release of confidential information could result in major regulatory and legal problems, so it’s highly important to ensure that records remain private and protected during a disaster.
For example, if an HIM professional discovers white powder on a paper document and suspects anthrax contamination, then the document must immediately be placed in a plastic bag and delivered to a laboratory for testing, Hughes says.
"You should do a chain-of-custody on the paper, including making a loan record to the person who will make certain it’s not anthrax," she says.
Then, if the paper turns out to be uncontaminated, it can be returned immediately to the department. If it is contaminated, it can be sterilized and returned when it’s deemed safe.
After Oklahoma City, health care providers often mentioned that it would be a good idea for the area to create a centralized computer database that all providers could share. This would have the benefit of giving families one place to go for information, Burrington-Brown says.
"HIPAA does allow for disasters and it does allow for the release of information to agencies who are legally or by charter dealing with disasters for the purpose of location of families in the case of a patient’s death," Burrington-Brown says.
To prepare for the documentation damage that a disaster could cause, HIM departments should contact fire or water damage restoration companies to determine what kinds of services they can provide in restoring electronic and paper documentation. (Read about contracting with restoration companies on p. 3.)
These companies also might have information that could help a department better prepare for a disaster. Also, HIM departments need to assess the facility’s insurance coverage to see what costs are covered during a recovery period and what strategies can be taken to limit liability and loss, according to a practice brief Hughes wrote.
When records cannot be reconstructed, an HIM department might look into various strategies, including reprinting documents from undamaged databases in admission, transcription, etc.; transcribing documents from the dictation system; and obtaining copies that were distributed to physician offices and others.
• Draft a disaster plan.
First, use what is already available.
"Most plans could work for all sorts of other disasters, but it would be appropriate for people to revisit those annually and tweak them in some way," Hughes says.
For instance, nearly all HIM departments probably created extensive electronic disaster plans as they prepared for Y2K. Those plans could be dusted off and used to prepare for an electronic attack, such as an Internet virus that destroys files.
"What you do is list your core and electronic processes, starting with a master patient index, for example, so that you can locate patient records," Hughes says.
Then take the function that’s electronic and list the various assumptions of what has caused the electronic failure or disaster and describe what might happen, what resulting problems will occur, what is available to the department in the event of the problem, and how to design ways to work around the problem, Hughes adds.
Examples of disasters that should have a similar flowchart or contingency checklist include fire, flood, bioterrorism event, hurricane, explosion, extended power outage, and earthquake. (To read about how to generate a contingency plan, see "Here are the essentials of a contingency plan," in this issue.)
If there is a terrorist attack or a major natural disaster, it’s possible that hospitals will be inundated with more patients than they believe they can handle, and these patients may arrive in unexpected ways, Burrington-Brown says.
"One thing I’ve seen in the experiences of people who worked through the Oklahoma City bombing or the New York City bombing is that the numbers of people they receive at hospitals is far more than they ever planned for," Burrington-Brown says. "Departments are saying, Let’s plan for 50 casualties, because that’s what our hospital can reasonably handle.’ But they need to plan for more than they can handle comfortably."
In the event of a major disaster, the people who are injured may not be organized by rescue workers and sent to hospitals in an orderly fashion. It’s likely that area hospitals will receive patients through a variety of means, including ambulances, private cars, and walk-ins, and it’s likely they’ll enter at any door of the hospital, as well as emergency department doors, says Burrington-Brown.
These types of scenarios affect HIM departments because patients may not always have identification and insurance coverage information on their person. They may be unconscious or disoriented and unable to answer questions by intake workers. Often their family members do not know where they are.
"You may have large numbers of people for whom you have no name, insurance, or other demographic information. So how do you track these people during their stay?" Hughes asks.
HIM staff may need to work with intake staff in identifying patients and gathering information, Burrington-Brown says.
One strategy under these circumstances is to develop a simple system of identification and clean up the documentation later, she says.
For example, after the terrorism attacks in Oklahoma City and New York City, hospital workers identified patients through tags with check boxes that listed physical characteristics, Burrington-Brown says.
"On the back of the tag were stickers with the same numbers as the tags, so that as samples were sent to the lab, the stickers and lab samples had the same numbers," Burrington-Brown says.
Even this system posed some unexpected consequences. Some patients were so traumatized by the disaster experience that they could not tolerate having anything tied to them, so the tags had to be put on clips, she adds.
• Learn from trials, tribulations, and mistakes.
HIM departments can learn from the problems other facilities have had during disasters, as well as from their own disaster drills and actual events.
This is why it’s important to practice disaster drills twice a year when possible, Burrington-Brown says.
And it’s a good idea for an HIM department to hold its own mini-disaster drill, independent of the hospitalwide drill, Hughes suggests.
"It’s not just having a plan written down, but having regular discussions with the staff to talk about what might happen and how any of them might need to be the boss and do what needs to be done when it happens," Hughes says.
An example of learning from others’ experiences might include stocking an HIM department with identification tags and clips that could be used in the event of an emergency in which victims cannot easily be identified, Burrington-Brown says.
"Stock three to five times more than you think you’ll need because you don’t know what your numbers will be," Burrington-Brown says. "And make sure the people involved know what to do with them, and that includes admitting people and HIM people."
Finally, keep in mind that after a disaster there may be heightened emotions and staff may be personally affected by deaths and injuries, so it’s important to let employees vent, grieve, and heal emotionally.
Once this process is under way, HIM professionals may begin to evaluate how the department handled the disaster and what can be done to improve the process in the event of future disasters.