Telemedicine Record Documentation and Retention

Telehealth technology has played an essential role in maintaining patient and provider safety during the COVID-19 public health emergency. Less stringent regulations and Federal Communications Commission stimulus money has allowed some physician offices to transition to 100% virtual offices while currently, 76 percent of U.S. hospitals connect with patients and consulting practitioners using video and other technology. This is a significant contrast from the 2.4% of people from large employer health plans who had utilized at least one telehealth service in 2018.

To assist with the increase in telehealth practices, the HHS Office for Civil Rights (OCR) now allows providers to utilize non-public facing applications like Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, or Skype. More established and secure virtual care platforms are offered from specialty providers like AmWell, MDLIVE, TelaDoc Health/InTouch Health and a variety of others.  While there are many more options to connect patients with care providers, the OCR still requires good faith in the use of telehealth methods.

One key requirement for telemedicine that remains the same as it is for traditional in-person visits is the requirement for medical record documentation. Documentation requirements for a telemedicine service are the same as for a face-to-face encounter. The information about the visit, the history, review of systems, consultative notes, or any information used to make a medical decision about the patient must be documented along with a note that the service was provided through telemedicine.

A recent update from AHIMA notes that as regulations remain fluid around these new virtual care settings, telemedicine systems documentation will be even more important than ever and will help post-crisis to ensure accurate billing, coding, and syndromic reporting can occur.

To that end, all telemedical records are considered equal to the patient’s primary health record and retained according to all applicable laws. Further, security and back-ups should be maintained according to best practices in case of a system failure.

At a minimum, AHIMA recommends each telemedicine record contain:

  • Patient name
  • Identification number
  • Date of service
  • Referring physician
  • Consulting physician
  • Provider organization
  • Type of evaluation performed
  • Informed consent, if appropriate (in many telemedicine programs, the referring physician/organization retains the original and a copy is sent to the consulting physician/organization.)
  • Evaluation results (In many telemedicine programs, the consulting physician/organization retains the original and a copy is sent to the referring physician/organization)
    Diagnosis/impression
  • Recommendations for further treatment

It is important to review the appropriate state laws and regulations for any specific requirements. For example, telemedical records media may be hard copy, video or audiotape, monitor strip, or electronic files. Some states specify acceptable media for health records. For more information about state telehealth laws, see the Center for Connected Health Policy’s State Telehealth Laws – Spring 2020 publication.

Information flow with telemedicine records is held at the same standard as traditional medical records.

Release of information and sharing telemedicine documentation and records with other providers follows the same requirements as an in-person medical record. As such, maintenance of telemedicine records should ensure that the organization can quickly assemble all components of a patient’s record, regardless of their location in the organization. In the absence of policies specifically addressing disclosure of telemedical information, disclosure should be allowed upon receipt of written authorization from the patient or legal representative or in accordance with court order, subpoena, or statute. Informed consent for telemedical encounters should include the names of both the referring physician and the consulting physician, and it should inform the patient that his/her health information will be electronically transmitted.

Many providers have integrated a telemedicine-specific application to assist with the bi-directional workflow needed to keep the EHR up to date, so the physician need only interact with a single platform. This integration increases efficiency and supports facilitating faster diagnosing, lowering prescribing errors, and as a result, improving patient outcomes.

As telemedicine continues to keep patient care moving forward during these unusual times and beyond, there will be EHR system upgrades and replacements that require planning and implementation of solutions for legacy health data. Much like the smooth integration of telemedicine applications that offer workflow benefits to the EMR, an active archive provides Single Sign-On from hospital-wide EMRs like Cerner® or Epic® to support efficient and immediate access to legacy health records at the point of care.

Migrating and storing legacy health data into an active archive, like HealthData Archiver®, makes all legacy health data accessible to physicians at the point of care (wherever that may be), as well as for eDiscovery purposes for the legal team, the HIM team that needs to fulfill a release of information request, and revenue cycle teams who need to perform legacy A/R Management.

Is your team charged with keeping the flow of health data moving across its entire lifecycle? Do you need legacy data availability from your remote offices as well as onsite at a healthcare center? Our team has award-winning experience in extracting, migrating and archiving data and images from over 500 EMR systems. Ranked #1 in the 2020 Best in KLAS Software & Services Report as a Category Leader in Data Archiving, we can help.

Jun 11 2020

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