Mission Statement
To safeguard the privacy and confidentiality of Behavioral Health Services (BHS) Protected Health Information (PHI) while promoting patient access to their Electronic Health Record (EHR) and facilitate continuity of care for service providers. HIM provides centralized, accurate and timely document retrieval and review, in compliance with Federal, State and Local regulations.
To ensure continuous learning and remain compliant with changes in laws and the fast-moving pace of technology, as related to patient access, interoperability and disclosure of sensitive protected health information.
Department Support
BHS Health Information Management (HIM) is a Behavioral Health Services department that is under the Integrated Records Information System (IRIS) Support Division within the County of Orange Health Care Agency – Authority & Quality Improvement Services (AQIS).
HIM is comprised of two teams: the Record Request Team and Record Quality Team.
Overall Activities
- Process, review and redact client records for Mental Health Plan (MHP) and Substance Use Disorder programs (SUD) retained electronically by county programs
- Manage the BHS Record Set categorization of documents within the EHR for privacy, security, access and for document retrieval or release
- Provide support and training to program staff for HIM functions in the EHR
- Identify and correct misfiled documents within the EHR
- Centralized retention of sensitive documents not retained in the EHR
- Provide Subject Matter Expertise (SME) for the design, implementation and upgrade of EHR applications
- Provide support to the Health Care Agency Custodian of Records (COR) and CEO Risk Management for Legal Holds and Public Record Access requests
Record Request Team
For BHS County programs: Provide centralized processing, review and redaction for client record requests.
- Receive MHP and SUD Program Record Requests from clients, third parties, the judicial system, insurance companies, Social Security Administration (SSA) and SSI Outreach
- Prior to disclosure, specialized staff thoroughly review the details of the Record Request and the Authorization to Disclose Protected Health Information (ATD), check the EHR for duplicate client charts and retrieve health information records
- Licensed clinicians apply specialized knowledge and technical skills to review for sensitive types of information such as Mental Health, SUD and AIDS/HIV
- Licensed clinicians redact documents in accordance with healthcare guidelines required by Federal and California State Privacy & Confidentiality laws
- Staff collaborate with the HCA Custodian of Records, SSA and SSI Outreach to ensure compliant, accurate, and timely release of records
- Staff consult with the HCA Office of Compliance and HCA County Counsel when needed
Record Quality Team
For BHS County programs: Provide program support for HIM related questions.
- Support the Record Request Team by processing requests for client records
- Conduct Quality Assurance reviews for EHR document accuracy and retention
- Coordinate EHR Scan Type changes and updates to EHR Scan Cover Sheets for MHP and SUD
- Create user guides for Authorization to Disclose Protected Health Information forms (ATDs) and other HIM related topics (e.g. Abuse Report Documents, Scanning Documents into the EHR, etc.)
- Provide individualized guidance and training for staff on HIM related topics
- Recommend improvements for systemic business workflows or technical issues that contribute to errors with client PHI, data and documentation
- Collaborate with HCA Information Technology, AQIS QA/QI Teams, BHS IRIS Liaison Team, Office Coordination Team and other BHS Program staff to implement changes
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