Intro to Health Information System and Health Data PDF

Intro to Health Information System and Health Data Instructor: Samah Hachem  To be able to discuss some of the most significant influences shaping the current and future health information technology landscapes To be able to understand some of the...

Intro to Health Information System and Health Data Instructor: Samah Hachem  To be able to discuss some of the most significant influences shaping the current and future health information technology landscapes To be able to understand some of the key concepts in HIT To be able to define health care data and information. Learning To be able to understand the major purposes for Outcomes maintaining patient records. To be able to discuss basic patient health record and claims content. To be able to discuss basic uses of health care data, including big and small data and analytics. To be able to identify common issues related to health care data quality. Introduction Since the early 1990s, the use of health information technology (HIT) across all aspects of the US health care delivery system has been increasing. Electronic health records (EHRs), telehealth, social media, mobile applications, and so on are becoming the norm—even commonplace—today HealthCare Information Systems Health Care Information Systems must examine the data and information they are designed to support. Types of Health Care Information depends on the organizations or companies: 1. Government or insurance company 2. Hospital, nursing home, or physician’s office Definition is often driven by the use or setting of the health information History !!! Problem? Research estimating that 44,000 to 98,000 patients die each year because of medical errors. Information is as critical to the provision of safe health care  Health Care Data Health Care Information Health Care Knowledge Health Care Information The majority of health care information created and used in health care information systems within and across organizations can be found as an entry in a patient's health record or claim. This information is readily matched to a specific, identifiable patient. Health Insurance Portability and Accountability Act (HIPAA) and Health Information Definition by HIPAA Health information is any information, whether oral or recorded, created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse. Scope of Health Information Relates to past, present, or future physical or mental health or condition of an individual, provision of health care, or payment for health care Protected Health Information HIPAA refers to this identifiable information as protected health information (PHI). Significance of Quality Health Information Creating, maintaining, and managing quality health information is crucial for health care organizations aiming for accreditation  Accreditation Standards Manuals Example: Record of Care, Treatment, and Services (RC) Outlines standards governing the components of a complete medical record. Information Management (IM) Outlines standards for managing information as an important organizational resource.  Medical Record versus Health Record Electronic medical records (EMRs) are digital version of the paper charts & contains the medical and treatment history of the patients in one practice-able clinicians (and others) to do the following: * Track data over time * Easily identify which patients are due for preventive screenings or checkups * Check how their patients are doing on certain parameters 'such as blood pressure readings or vaccinations *Monitor and improve overall quality of care within the practice Electronic health records (EHRs) Patient Record Purposes Patient Care” Records form Communication :Facilitates the documented basis for communication among planning and providing healthcare team members, patient care across episodes ensuring cohesive and and the continuum of care. informed care. Billing and Legal Reimbursement :Documenta Documentation :Records act tion is essential for verifying as legal evidence of the care services billed to insurance provided, crucial in legal companies and federal actions. programs. Addition Research and Quality Management: Used to monitor care quality and for research al purposes in various healthcare settings Purpose Population Health: Measures health outcomes, service s of utilization, and adherence to guidelines within communities. Patient Public Health:Informs policies and procedures aimed at Records protecting public health through agency analysis. Personal Health Records (PHRs) Identification Screen : Includes patient demographics and clinical identifiers. Problem List :Maintains a comprehensive list of significant medical issues and operations. Medication Record: Tracks prescribed and administered medications and allergies. History and Physical: Documents the patient's history and physical examination findings. Progress Notes: Detailed notes by various providers documenting patient response and care plans. Consultation Reports: Opinions from additional providers requested by the primary physician. Physician Orders :Directives regarding patient care, including medications, tests, and treatments. Personal Health Records (PHRs) Imaging and X-ray reports: Interpretation and findings of images by the radiologist. Laboratory reports: Laboratory reports contain the results of tests conducted on body fluids, cells, and tissues by lab personals and results by physician Consent and authorization forms: Copies of consents to admission, treatment, surgery, and release of information are an important component of the patient record related to its use as a legal document often provided by the practitioner. Operative report: Operative reports describe any surgery performed and list the names of surgeons and assistants Pathology report: Pathology reports describe tissue removed during any surgical procedure and the diagnosis based on examination of that tissue. Discharge summary: Each acute care patient record contains a discharge summary. The discharge summary summarizes the hospital stay, including the reason for admission, significant findings from tests, procedures performed, therapies provided, responses to treatments, condition at discharge, and Population Health With the passage of the Accountable Care Act (ACA) and other healthcare payment reform measures, organizations and communities have begun to shift focus from episodic care to population health. Population health focuses on maintaining health and managing healthcare utilization for a defined population of patients or community with the goal of decreasing costs. Comprehensive Shared Care Plan (CSCP) Diagnostic and Procedural Codes Captured during the patient encounter, not only to track clinical progress but also for billing, reimbursement, and other administrative purposes. Two major coding systems ICD-10 (International Classification of Diseases) CPT (Current Procedural Terminology), published by the Americann Medical Association  Health Care Data Health Care Data Analysis Three basic elements: 1- Source of Data 2- Retrievable from a Database or Data warehouse 3- Reported in usable manner Health Care Data Quality Philip B. Crosby and Joseph M. Juran. Juran (Juran & Gryna, Crosby (1979) defines 1988) defines quality quality as as “fitness for use,” “conformance to products or services requirements” or must be free of conformance to deficiencies standards.  American Health Information Management Association (AHIMA) Data Quality Characteristics Weiskopf and Weng (2013) five dimensions of EHR data quality Case 1: Documentation Errors A nurse administered 5,000 units of Heparin when the order was for 2,500 units. The patient became critically ill as a result. When the documentation was reviewed, it was discovered that the nurse committing the error had misspelled Heparin as ‘‘Hepirin.’’ This spelling error was presented to the jury as an additional demonstration of incompetence. The plaintiff’s attorney argued that Heparin is a commonly used drug and obviously this nurse had no knowledge of it, because she couldn’t spell it correctly. Juries will also doubt the competence of a nurse who writes ‘‘The wound on the left heal is healed.’’ Strategies for Minimizing Data Quality Issues Data dictionary Designing data elements to avoid errors (e.g., using check digits, algorithms, and well-designed user interfaces) Developing and adhering to guidelines for documenting the care that was provided Building human capacity, including training, awareness- building, and organizational change Instituting real-time quality checking, including the use of validation and feedback loops  Consider a patient (real or imagined) with a chronic health condition. Identify at least three actual health care providers that this patient has seen in the past twelve months. Draw a diagram to illustrate the timeline of the patient's encounters. Considering these encounters, how easy is it for each provider to share health care information regarding this patient with the others? What are the barriers to the communication and sharing of health care information? How will this affect the patient's overall care?