Hybrid Health Record

Electronic Health Records (EHR) transition from paper to electronic has necessitated a “hybrid” environment. The combination of paper, EHR, and document imaging (scanning) is causing challenges for Health Information Managers (HIM). Paper forms are still utilized by some Healthcare Providers due to necessity or due to limitations of the EHR. Practitioners must be able to access and input information into an EHR or onto a form that will be later scanned into the EHR, and that information must meet legal requirements.

There are many strengths noted in utilizing a Hybrid EHR. Hybrid records allow for paper and electronic records to be accessed by multiple practitioners at the same time. These also allow for the Health Records Technician to ensure that the legal requirements of the EHR are met. Ensuring that practitioners can access lab results, radiology reports, previous notes from other visits, sending and receiving notes from outside referrals and other functions make Hybrid records valuable to the Health Providers.

Some of the weaknesses of the Hybrid EHR become apparent only when actually implementing the process. When a document is scanned into the record, the HIM staff must ensure a crosswalk is created. Crosswalks are structures within the EHR that include headings, such as “Discharge Documents”, and subheadings that are useful such as “Discharge Instructions”, “Discharge Summaries” or “Admission Information”.

These crosswalks allow for a practitioner to access information electronically, and should be aligned with how the paper chart is accessed prior to the implementation of an EHR. Ancillary reports follow below subheadings. Physicians and nurses create paper charts, and that chart, when patient is discharged, is scanned into the EHR by an HIM. That data then becomes part of the legal document. A legal medical record is described as residing wherever the document is born. When information is created in the form of an electronic database, which is the legal record.

The EHR must be considered a document that can be subpoenaed for legal proceedings. Signatures, whether electronic or paper, must be documented in a master list that follows the chart at all times. The master signature list ensures that anyone that accessed the record, added or deleted information, and had direct care for the patient is appropriately documented. When a Request for Information (ROI) is generated, a hybrid EHR becomes a good choice. The hybrid record, when imaging is used, allows for complete releases by the HIM without having to data mine the paper records.

This increases productivity in the HIM by decreasing the time to find and copy data, and decreased the amount of paper required when the ROI can be fulfilled with electronic data transfer instead of paper being sent. The “Willow Bend Record Policy” was established to establish guidelines for retention, storage, and destruction of health information. I will be evaluating this policy/procedure for compliance with Washington State Administrative Code (WAC) and the Revised Code of Washington (RCW), Medicare Conditions of participation, and HIPPA compliance. Washington State Law (WAC 248-318-440) sets the requirements for acute care medical record retention.

The Willow Bend Hospital compliance list follows:

1) WAC requires no less than 10 years following most recent discharge for all medical records and the Master Patient Index (MPI), Willow Bend meets this requirement except that Willow Bend only requires 5 years for imaging.

2) The WAC does not discuss the Disease Index specifically.

3) WAC requires all minor records be kept 3 years following age 18, or 10 years following last discharge, whichever is longer. Willow Bend exceeds this by requiring that Fetal Heart Records be kept 10 years after the age of majority.

4) The MPI, under the WAC is only kept for 10 years following most recent discharge. Willow Bend exceeds this requirement by permanently maintaining the MPI Permanently.

5) The WAC does not specifically discuss the operative index.

6) Adult Medical records meet WAC requirements by keeping them for 10 years following last encounter.

7) The WAC requires Minor medical records must be maintained 3 years following the age of 18, or 10 years following most recent discharge, whichever is longer. Willow Bend matches this requirement by stating “age of majority plus statute of limitations”.

8) Physician Index is not referenced in the WAC and Willow Bend requires 10 years of retention. 9)Birth Registry, Death Registry and Surgical Procedure Registry are required to be permanently retained by WAC and by Willow Bend. The Centers for Medicare Services (CMS) follows the HIPPA guidelines for retention of records. State laws generally govern the retention of medical records.

CMS requires that records of providers submitting cost reports to be retained in their original or legally reproduced form for 5 years following the closure of the cost report. HIPPA does not include medical retention requirements; it does require that covered entities apply appropriate administrative, technical and physical safeguards to protect the privacy of medical records and other protected health information. Hybrid health records provide an excellent bridge between paper and electronic records. Legal requirements must be met, but when these are fulfilled, EHR’s become a repository for accessible and legal information for providers of healthcare.


  • Centers for Medicare and Medicaid Services. (2010). Medical Record Retention and Media Formats for Medical Records. Available http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1022.pdf. Last accessed 4th Oct 2012.
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