Health Informatics: Understanding Health Care Information Systems and Data Quality, Study notes of Management of Health Service

Download Health Informatics: Understanding Health Care Information Systems and Data Quality and more Study notes Management of Health Service in PDF only on Docsity! Health Informatics / TEST 1 / Fall 2010  Information System (IS): an arrangement of information (data), processes, people, and information technology that interact to collect, process, store, and provide as output the information needed to support the organization  Information Technology (IT): a contemporary term that describes the combination of computer technology (hardware and software) with data and telecommunications technology (data, image, and voice networks). Often used interchangably with Information System.  Health Care Information System (HCIS): an arrangement of information (data), processes, people, and information technology needed to support the health care organization. 2 Primary Classes of HC Information Systems:  Administrative IS: o Mainly used for administrative information and financial data o Used to support management and general operations of a HC Facility  Clinical IS: o Contains clinical or health related information relevant to provider o Used in diagnosing, treating, and monitoring patient care.  Administrative Examples o Patient Admin. Systems  Admission, Discharge, Transfer Registration  Scheduling  Billing  Utilization Management o Financial Management Systems  Anything Finanacial  Clinical Examples o Ancillary IS :  Laboratory  Radiology  Pharmacy  Other IS Components: o Nursing Documentation o EMR o Computerized Provider Order Entry o Tele-medicine/health Health Informatics / TEST 1 / Fall 2010 Types of HC Information Technology:  Framework o Internal Data/Info  Patient Encounter  Patient Specific  Aggregate  Comparative o General Operations o External Data/Info  Comparative  Expert/Knowledge-based o Patient Specific – Clinical --- (Purpose of Patient Records)  Patient Care  Communication  Legal Documentation  Billing and Reimbursement  Research and Quality Management o Patient Specific – Administrative  Data Needed for Reimbursement  UB-04  CMS-1500  Other Uniform Data Sets  ACDS  UHDDS of 1986  MDS  UHDDS : (Uniform Hospital Discharge Data Set) Elements: o Personal ID, Sex, Race, Ethnicity, Residence, Hospital ID, Admission/Discharge dates, etc.. o Patient Specific – Combined:  Coding Systems  ICD-9-CM o National Center for Health Stats o Inpatient/Outpatient diagnosis & procedures o Aggregate IS – Clinical: Health Informatics / TEST 1 / Fall 2010 Problems with Poor Quality Data:  Data quality must be established at the most granular level  Much HC information is gathered via patient care documentation  Most clinical information generated by the HC organization. o Source of this is the PATIENT RECORD  Incomplete and inaccurate medical records are root of most HC organization’s problems 2 Parts of HC Documentation:  (1) Information Capture o The process of recording representations of human thought, perceptions, or actions in documenting patient care, as well as device-generated info that is gathered or computed about a patient as part of health care  (2) Report Generation o Consists of the formatting and/or structuring of captured information. o The process of analyzing, organizing, and presenting recorded patient information for authentication and inclusion in the patients’ health record.  AHIMA: o American Health Information Management Association o Unique patient identification must be assured within and across HC documentation systems. o Health Care Documentation must be:  Accurate and consistent  Complete  Timely  Interoperable across different types of documentation systems  Auditable o Confidential and secure authentication and accountability must be provided.  AHIMA – Review of Common Dimensions o Data Accuracy: Data that reflect correct, valid values are accurate. Typographical errors in discharge summaries and misspelled names are examples of inaccurate data. o Data Accessibility: Data that are not available to the decision makers needing them are of no use. Health Informatics / TEST 1 / Fall 2010 o Data Comprehensiveness: All of the data required for a particular use must be present and available to the user. Even relevant data may not be useful when they are incomplete. o Data Consistency: Quality data are consistent. Use of an abbreviated that has two different meanings provides a good example of how lack of consistency can lead to problems. For example – a nurse may use the abbreviation to CPR to mean cardiopulmonary resuscitation at one time and use it to mean computer- based patient record at another time. o Data Currency: Many types of health care become obsolete after a period of time. A patient’s admitting diagnosis is often not the same as the diagnosis recorded upon discharge. If a health care executive needs a report on the diagnoses treatment during a particular time fram, which of these two diagnoses should be included? o Data Definition: Clear definititions of data elements must be provided so that both current and future data users will understand what the data mean. One way to supply clear data definitions is to use data dictionaries. o Data Granularity: A.K.A. ~ Data Atomicity  Individual elements are “atomic” in a sense that they cannot be further subdivided.  Example: the way a patient’s name should be stored (Last, First, Middle)  Related to the purpose for which the data are collected o Data Precision:  Often relates to numerical data. Precision denotes how close to an actual size, weight, or other standard a particular measurement is. o Data Relevancy:  Data must be relevant to the purpose for which they are collected o Data Timeliness:  Is a critical dimension in the quality of many types of HC data.  AHIMA defined ‘4 Parts of Data Quality Management Model: o Application: The purpose for which the data are collected o Collection: The processes by which data elements are accumulated o Warehousing: Processes and systems used to archive data and data journals o Analysis: Process of translating data into information utilized for an application  MRI: o Medical Records Institute Data Errors: Health Informatics / TEST 1 / Fall 2010  Systematic Errors: o Errors that can be attributed to a flaw or discrepancy in adherence to standard operating procedures or systems  Ex: Diagnosing coding errors o Can be caused by unclear data definitions or a failure to comply with established data collection protocols  Such as leaving out required information  Licensure: o Process that gives a facility legal approval to operate o State governments oversee o Generally renewed annually  Certification: o Gives a HC organization the authority to participate in CMS  Conditions of Participation (COP):  A set of minimum standards  Accreditation: o An external review process that an organization elects to undergo o Hospitals accredited by TJC are ‘deemed’ to have met the federal certification standards o TJC performs onsite survey every 3 years o A Sentinel Event can put an organization on Accreditation Watch o TJC’s main focus is the quality of care provided in HC facilities  Information Management: o Goal : To support decision-making to improve patient outcomes, improve HC documentation, assure patient safety, and improve performance in patient care, treatment, and services, governance, management, and support processes.  NCQA: o National Committee for Quality Assurance o Serves as an accrediting body for health plans and managed care organizations o Accreditation process is viewed as ‘rigorous’ o Provides a free online Health Plan Report Card  Shows accreditation status of all plans it has surveyed  CARF: o The Commission on Accreditation of Rehabilitation Facilities  AAAHC: o The Accreditation Association for Ambulatory Health Care  Legal Health Record (LHR): Health Informatics / TEST 1 / Fall 2010 c. Description of destroyed records d. Inclusive dates of destroyed records e. A statement that records were destroyed in the normal course of business f. Signatures of individuals supervising and witnessing the destruction 3. Maintain the destruction documentation indefinitely  Covered Entities: o Those individuals and organizations that must comply to HIPPA Privacy Laws and regulations related to privacy and confidentiality o Include:  Health plans, which pay or provide care  Health care clearinghouses, which process health information (ex – billing services)  Health care providers who conduct certain financial and administrative transactions electronically  Turnkey Systems: (1970s) – software system that was developed by a vendor and installed on a hospital’s computers. o All hospital had to do was turn the system on and it was fully operational. o Con: Rarely turnkey systems could be modified to meet the unique information needs of an organization, however. “What you see is what you get” with a turnkey system.  Why Health Care Lags in IT: 1. Health care information is complex, unlike bank transactions for example. In this sense, it can also be difficult to structure because Health Care Information may contain images, text, pictures, and other graphics. a. Health Care Information terminology is also complex and not consistently used among clinicians 2. Health Information is highly sensitive and personal even though it is related to a person’s diagnosis and treatment. Every patient must feel comfortable sharing such information with health care providers and confident that their information will be kept confidential and secure. a. Younger, more tech savvy individuals are beginning to take advantage of PHRs which may help the trust issue in the future since it is up to patient to keep information secure. 3. Health care information technology is expensive and currently it’s the health care provider and/or provider’s organization that currently bears the brunt of the cost for acquiring, maintaining, and supporting these systems. Health Informatics / TEST 1 / Fall 2010 4. U.S. health care system is not a single system, it is conglomeration of systems made up of health care organizations of all kinds, both public and private. a. Connectivity issues between organizations and providers b. Integration issues