Health Information Management Technology PDF

Health Information Management Technology: An Applied Approach, Sixth Edition Chapter 3: Health Information Functions, Purpose, and Users ahima.org ahima.org © 2020 AHIMA Introduction Who, what, when, why, and how of patient care Data Information Knowledge ahima.org © 2020 AHIMA Primary Purposes of t...

Health Information Management Technology: An Applied Approach, Sixth Edition Chapter 3: Health Information Functions, Purpose, and Users ahima.org ahima.org © 2020 AHIMA Introduction Who, what, when, why, and how of patient care Data Information Knowledge ahima.org © 2020 AHIMA Primary Purposes of the Health Record Patient care Management of patient care Administrative processes ahima.org © 2020 AHIMA Secondary Purposes Education of healthcare professionals Legal, accreditation, and policy development Public health and research ahima.org © 2020 AHIMA Formats of the Health Record Paper health record Electronic health record Hybrid health record ahima.org © 2020 AHIMA Primary Users – Healthcare Providers Patient record Aggregated Deidentification ahima.org © 2020 AHIMA Individual Users Patient care providers Patient care managers and support staff Coding and billing staff Patients Employers Lawyers Law enforcement officials Healthcare researchers and clinical investigators Government policy makers ahima.org © 2020 AHIMA Institutional users Healthcare delivery organizations Third-party payers Medical review organizations Research organizations Educational organizations Accreditation organizations Government licensing agencies Policy-making bodies ahima.org © 2020 AHIMA Medical Transcription and Voice Recognition Transcription In-house or outsourced Documents transcribed Transcription supervisor Quality of reports Timeliness of transcription Speech recognition ahima.org © 2020 AHIMA Release of Information Disclosing patient-identifiable information In-house or outsourced ROI supervisor Monitor quality Turnaround time ahima.org © 2020 AHIMA Clinical Coding and Reimbursement Coding Abstracting Bill Coding supervisor Quality of codes Timeliness ahima.org © 2020 AHIMA Record Storage and Retrieval Transitioning from paper to electronic Document management system Hybrid health record ahima.org © 2020 AHIMA Master Patient Index Permanent record of all patients treated at healthcare organization Demographics Used in numeric filing system Enterprise master patient index ahima.org © 2020 AHIMA EMPI– Recommended Core Data Elements Internal patient identification Person name Date of birth Gender Race Ethnicity Address Telephone number Alias, previous, or maiden names Social security number ahima.org © 2020 AHIMA Facility identification Universal patient identifier Account or visit number Admission or visit number Admission, encounter, or visit data Discharge or departure date Encounter service type Encounter primary physician Patient disposition Quality Issues in MPI Systems Typographical errors Outdated demographic information Incorrect names Duplicate Overlay Overlap ahima.org © 2020 AHIMA Algorithms Deterministic Probabilistic Rules-based ahima.org © 2020 AHIMA Paper-based Filing Systems Alphabetic Numeric Straight numeric Terminal-digit Alphanumeric Centralized unit ahima.org © 2020 AHIMA Paper-based Storage Filing cabinets Shelving units Open Compressible ahima.org © 2020 AHIMA Purging Space Readmission rate Access to health record ahima.org © 2020 AHIMA Paper-Based Storage Image-based Scanned document Index Cannot search document ahima.org © 2020 AHIMA Paper-based Storage File folder Color coding Microfilm Roll Jacket Microfiche ahima.org © 2020 AHIMA Off-site Storage Healthcare organization or commercial company Protect records Privacy Physical Access ahima.org © 2020 AHIMA Paper-Based Retrieval and Tracking Outguide Loose material Requisition Chart tracking system ahima.org © 2020 AHIMA Paper-based Record Processing Organize Meet standards Record reconciliation Assembly Analysis Qualitative Quantitative—concurrent or retrospective ahima.org © 2020 AHIMA Monitoring Completion Deficiency slip Incomplete health records Delinquent record ahima.org © 2020 AHIMA Correction, Addendum, Amendment Corrections Draw line Write “error” Sign, date, and time correction Addendum Date of addendum Signed and timed Amendment Dated, timed, and signed ahima.org © 2020 AHIMA Form Design Identify purpose of form Include all necessary data Users involved in development ahima.org © 2020 AHIMA Form Design Principles Unique form identification Date created or revised Title Facility name and logo Patient identification information Signature line ahima.org © 2020 AHIMA Form Design Principles Content in order of data entry, if appropriate OCR and barcodes—upper corner 8.5 × 11 Black ink on white paper Sufficient space to write ahima.org © 2020 AHIMA Clinical Forms Committee Interdisciplinary Standards for forms ahima.org © 2020 AHIMA Forms Control Program Establish standards Establishing a number and tracking system Establishing a testing and evaluation plan Checking the quality of new forms Systematizing storage, inventory and distribution Establishing a forms database ahima.org © 2020 AHIMA Quality Control Standards Monitoring Misfiles Timeliness of storage and retrieval Record completion ahima.org © 2020 AHIMA Electronic Environment Reducing storage of paper records Audit trail Indexing Health record completion Work queue ahima.org © 2020 AHIMA Electronic Environment Version control Free text Structured data ahima.org © 2020 AHIMA Electronic Environment Copy and paste Inaccurate or outdated information Redundant information Inability to identify the author or intent of documentation Inability to identify when the documentation was first created Propagation of false information Internally inconsistent progress notes Unnecessarily lengthy progress notes ahima.org © 2020 AHIMA Electronic Environment Digital dictation Speech recognition Natural language processing Reconciliation E-mail, voice mail, EKG, and more ahima.org © 2020 AHIMA Electronic Environment Materials from other healthcare organizations Search, retrieve, and manipulate health data Data mining Amendments and corrections ahima.org © 2020 AHIMA Quality Control—Data Entry Scanning Data entry Barcodes Transfer of data ahima.org © 2020 AHIMA Quality Control—Data Entry Input mask Drop down box Check box Radio buttons ahima.org © 2020 AHIMA Screen Design Clear navigations buttons Labeling of buttons and fields Limit abbreviations Consistent location of navigation buttons Alerts References Check ahima.org © 2020 AHIMA Screen Design Logical organization Neutral colors Undo buttons Confirmation buttons Require fields Title for screen ahima.org © 2020 AHIMA Screen Design Minimize keystrokes Appropriate field type Select from predefined lists when possible Data validation checks ahima.org © 2020 AHIMA Identification Systems Health record number: a unique identifier Paper-based health record Serial numbering Unit numbering Serial-unit numbering Alphabetic ahima.org © 2020 AHIMA EHR—Unit Numbering Patient account Health record number Other identifiers ahima.org © 2020 AHIMA Other HIM Functions Statistics Research Registries Birth and death certificates ahima.org © 2020 AHIMA HIM Functions Work with other departments Patient care Information governance Quality management Billing Patient registration ahima.org © 2020 AHIMA HIM Interdepartmental Relationships Patient registration Billing department Patient care departments Information systems Quality management Virtual HIM ahima.org © 2020 AHIMA HIM Information Systems Release of information Chart tracking Coding Registries Billing Quality improvement ahima.org © 2020 AHIMA HIM Information System Electronic health record Personal health records ahima.org © 2020 AHIMA