Electronic Health Records: Roles, Functions, and Quality in Health Info Management, Exams of Nursing

Download Electronic Health Records: Roles, Functions, and Quality in Health Info Management and more Exams Nursing in PDF only on Docsity! HIM Technology: An Applied Approach AHIMA Test 1 - chap 1- 6 This includes chapters 1 and 2 HIM Health Information Management - 1928 recognized as allied health professional AHIMA American Health Information Management Association - PURPOSE: to ensure the quality, confidentiality, and availability of health information across diverse organizations, settings, and disciplines. 3 distinct steps influenced development of the HIM profession: - 1. The hospital standardization movement, 2. the organization of records librarians, and 3. the approval of formal educational processes, and a curriculum for medical record librarians The hospital standardization movement - 1918 American College of Surgeons (ACS) inaugurated the Hospital Standardization Program to raise the standards of surgery by establishing a minimum quality standards for hospitals. One of the most important items in the care of a patient was complete and accurate report of the care and treatment provided during hospitalization. Complete medical record must include: - identification data; complaint; personal and family history; history of the present illness; physical examination; special examinations such as consultations, clinical laboratory, x-ray, and other examinations; provisional or working diagnosis; medical or surgical treatment; gross or microscopical pathological findings; progress notes; final diagnosis; condition on discharge; follow-up; and in case of death, autopsy findings. CAHIIM - Commission on Accreditation for Health Informatics and Information Management Education - school accreditation Certification Board - AHIMA CCHIIM - Commission on Certification for Health Informatics and Information Management. - establishes criteria for eligibility for registration AHIMA - Title changes - 1970/1991 reflected the changing nature of the roles and functions of the association's professional membership. In 1991 changed from managing records to managing information. RRA - registered record administrator became a registered health information administrator (RHIA) and a ART - accredited record technician became a registered health information technician (RHIT) Health Information Manager for integrated systems - is responsible for the organizational wide direction of health information functions The clinical data specialist - responsible for data management functions, including clinical coding, outcomes management, and maintenance of specialty registries and research databases Patient informaiton coordinator - assists consumers in managing their personal health information, including personal health histories and release of information Data quality manager - responsible for data management functions that involve formalized continuous quality improvement activities for data integrity throughout the organization, such as data dictionary and policy development and data quality monitoring and audits. Information security manager - responsible for managing the security of electronically maintained information, including the promotion of security requirements, policies, privilege systems and performance auditing. Data resource administrator - manages the data resources of the organization, such as data repositories and data warehouses. Research and decision support specialist - Health Record - principle repository (storage place) for data and information about the healthcare services provided to an individual patient. Documents the who, what, where, and why and how of patient care. Also records the health status of the patient. PRIMARY FUNCTION IS TO STORE PATIENT CARE DOCUMENTS AND SUPPORT PATIENT CARE SERVICES. Secondary purpose is related to the environment in which healthcare services are provided. Equally important it helps physicians, nurses, and other caregivers make diagnoses and choose treatment options. It is an interactive tool for clinical problem solving and decision making. data - represent the basic facts about people, processes, measurements, conditions, and so on. They can be collected in the form of dates, numerical measurements and statistics, textual descriptions, checklists, images, and symbols. After data is collected and analyzed, they are converted into a form that can be used for a specific purpose and then is called "information" DATA REPRESENTS FACTS information - collected data that has been analyzed and converted into a form that can be used for a specific purpose. INFORMATION REPRESENTS MEANING EHR - electronic Health Record - electronic health record system designed for the use by healthcare providers and support the legal mandate providers have to document care. PHR - Personal Health Record - health record initiated and maintained by an individual Primary functions of health record - Patient care delivery (Patient): To document services received; to constitute proof of identity; to self-manage care; to verify billing. Patient care Delivery (Provider): to foster continuity of care (that is to serve as a communication tool); to describe diseases and causes (that is to support diagnostic work); to support decision making about diagnosis and treatment of patients; to assess and manage risk for individual patients; to facilitate care in accordance with clinical practice guidelines; to document patient risk factors; to assess and document patient expectations and patient satisfaction; to generate care plans; to determine preventive advice or health maintenance information; to provide reminders to clinicians; to support nursing care; to document services provided; Patient Care Management: to document case mix in institutions and practices; to analyze severity of illness; to formulate practice guidelines; to manage risk, to characterize the use of services to provide the basis for utilization review; to perform quality assurance. Patient Care Support: to allocate resources; to analyze trends and develop forecasts; to assess workload; to communicate information among departments. Financial and Other Administrative Processes: to document services for payments; to bill for services, to submit insurance claims; to adjudicate insurance claims; to determine disabilities (for example, workmen's compensation); to manage costs; to report costs; to perform actuarial analysis Secondary purposes of the health record: - Education: to document the experience of healthcare professionals; to prepare conferences and presentations; to teach healthcare students. Regulation: to serve as evidence in litigation; to foster postmarketing surveillance; to assess compliance with standards of care; to accredit professionals and hospitals; to compare healthcare organizations. Research: to develop new products; to conduct clinical research; to assess technology; to study patient outcomes; to study effectiveness and cost-effectiveness of patient care; to identify populations at risk; to develop registries and databases; to assess the cost- effectiveness of record systems. Public Health and Homeland Security: to monitor public health; to monitor bioterrorism activity. Policy Making and Support: to allocate resources; to conduct strategic planning. Industry: to conduct research and development; to plan marketing strategy. Primary users of the health records are: - patient care providers - others include: Managed care organizations, integrated healthcare delivery systems, regulatory and accreditation orgs, licensing bodies, educational orgs, third-party payers, and research facilities. The IOM (Institute of Medicine) defines the users of health records as: those individuals who enter, verify, correct, analyze, or obtain information from the record, either directly or indirectly through an intermediary. Aggregate data - extracted data from individual health records and combined to form de-identified information about groups of patients that can be compared and analyzed. HIPPA - Health Insurance Portability and Accountability Act 1996 - includes health record security and privacy provisions. Grants most patients the right to access their health records. They have the right to request an amendment to the information in their records and to add missing information. They can review their records for documentation of services provided to verify and substantiate billed charges. Many obtain copies to incorporate into their PHR The Joint Commission - Accreditation Organization for healthcare facilities CMS - Centers for Medicare and Medicaid Serivces - a division of the US department of Health and Human Services and is responsible for administering the federal Medicare program and the federal portion of the Medicaid program. Attributes of Storage: - Quality, accessibility, security, flexibility, connectivity, and efficiency. Quality - is dependent on the design of the orgs systems and processes for collecting the original information. Incomplete or inaccurate records could compromise a patient's care or diagnosis. quality characteristics are: accuracy, accessibility, comprehensiveness, consistency, currency, definition, granularity, precision, relevancy timeliness Data accurracy - means that data are correct and is dependent on: the patient's physical health and emotional state at the time the data was collected; the provider's interviewing skills; the provider's recording skills; the availability of the patient's clinical history; the dependability of the automated equipment; the reliability of the electronic communications media. Data accessibility - means that the data are easily obtainable. Factors affecting the accessibility of health record data information: whether previous health record are available when and where they are needed; whether dictation equipment is accessible and working properly; whether transcription of dictation is accurate, timely, and readily available to healthcare providers; whether computer data-entry devices are working properly and are readily available to healthcare providers; whether the computer network and servers are accessible and working properly. Technology based access control mechanisms include the use of passwords, access cards or tokens, biometric devices, workstation restrictions, and role-based restrictions. Data Comprehensiveness/Completeness - means that all the required elements are included in the health record.