Domain 2 a

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Discussion Videos Each week you’ll be introduced to a new RHIT Exam Domains. Domains are clusters of knowledge and tasks that are the basis of the RHIT Exam and represent a percentage of the exam.

You can locate the domain listings in the Candidate’s Guide located on the AHIMA website. http://www.ahima.org/certification/RHIT

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February 2018

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Domain 1: Data Content, Structure, and Information Governance

Document # 2956-05A

Property of Rasmussen College

Copy Right Protected

March 2018

Slide 3 Disclaimer

• Please note that this presentation is designed to serve as a valuable supplement to your overall study plan to prepare for the RHIT certification examinations.

• Participation in these presentations alone does not guarantee a passing score on the examination. For more information on the testing dates and the RHIT credentials go to www.ahima.org.

• It is suggested that you follow the AHIMA Candidate Guide, Appendix H as a study guide preparing for your certification exam.

Slide 4 Domain 1: Data Content, Structure, and Information Governance (24-28%)

• Apply health information guidelines (e.g. coding guidelines, CMS, facility or regional best practices, federal and state regulations)

• Apply healthcare standards (e.g. Joint Commission, Meaningful Use)

• Define the legal health record

• Maintain the integrity of the legal health record

• Audit content and completion of the legal health record (e.g. validate document content)

• Maintain secondary health information (e.g. patient registration, financial records)

• Educate clinicians on documentation and content

• Coordinate document control (e.g. create, revise, standardize forms)

• Maintain the MPI

Slide 5 HIM: Six functional components

Source: AHIMA

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Legal Health Record Role of the LHR includes documentation to support clinical treatment decisions, revenue reimbursement for services rendered, legal testimony related to patient’s disease process, injury, treatment, decisions related to treatment and the patient’s response to treatment.

Slide 7 Defining the Legal Health Record

• The Legal Health Record by definition was simple with traditional paper records and included the content along with x-rays. The legal health record and the health record were the same.

• Definition changed with the introduction of the EMR

• Current definition of what is considered the Legal Health Record is complicated.

• Each healthcare organization must define what the LHR contains.

Slide 8 Legal aspects of the Legal Health Record

• Records from other providers may or may not be included in the legal health record

• Each organization should consult with their legal counsel as to incorporate records from outside providers as part of their own LHR.

• Some state laws dictate what can and cannot be included in the healthcare organization’s LHR

• Policies and procedures must be written to formalize the organization’s approach to define the record.

Slide 9 EHRs as Legal Health Record

• In order for the EHR to be a legal health record and meet the requirements as such, several concepts need to be considers

• How documentation is actually created and signed off by providers

• How documentation is managed and preserved

• How documentation impacts and interacts with the revenue cycle functions of billing and claims submission

• How the documentation is displayed both electronically to the user as well as in hard copy form

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Coordinate Document Control Create, revise, standardization of forms (screens)

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• An important part of ensuring adequate health record content is the function of forms design and development.

• The basic concept behind any form is that it must meet the needs of the end user

• One of the first steps in forms design is to identify the purpose, use, and potential users of the form.

• The principles of good design are critical when forms are used in document imaging systems.

Forms Design, Development, and Control for Paper- based Records

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• Clinical Forms Committee

– The committee should provide oversight for the development, review, and control of all enterprise-wide information capture tools, including paper forms and design of computer screens.

– The committee should be composed of information users

• Forms Control, Tracking, and Management

– Establishing standards

– Establishing a numbering and tracking system

– Establishing a testing and evaluation plan

– Checking the quality of new forms

– Systematizing storage, inventory, and distribution

– Establishing a forms database

Forms Design, Development, and Control for Paper- based Records

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Slide 14 Data Dictionary • An important element of health IT is a data

dictionary which lists all data elements and characteristics within a specific system.

• Common Data elements

– Data fields

– Data type

– Format

– Field size

– Data values

– Data sources

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COMPONENT FUNCTION

Registration Record Documents demographic information about the patient

Medical History Documents the patient’s current and past health status

Physical examination Contains the provider’s findings based on an examination of the patient

Clinical observations Provide a chronological summary of the patient’s illness and treatment as documented by physicians, nurses, and allied health professionals

Physician’s orders Document the physician’s instructions to other parties involved in providing the patient’s care, including orders for medications and diagnostic and therapeutic procedures

Reports of diagnostic and therapeutic procedures

Describe the procedures performed and give the names of clinicians and other providers; include the findings of x-rays, mammograms, ultrasounds, scans, laboratory tests, and other diagnostic procedures

Consultation Document opinions about a patient’s condition furnished by providers other than the attending physician

Discharge Summary Concisely summarizes the patient’s stay in a hospital

Patient Instructions Document the instructions for follow-up care that the provider gives to the patient or the patient’s caregiver

Consents, authorizations and acknowledgement

Document the patient’s agreement to undergo treatment or services, permission to release confidential information, or recognition that information has been received

Source: Sayles, 2014

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Secondary Health Information The primary data source is the patient’s health record. Data is abstracted and used as secondary health information for many different things.

Slide 17 Secondary Health Data

• Purpose • 4 major purposes for collection

• Quality, Performance and Patient Safety

• Research

• Population Health • Administrative

• Types • Facility Specific

• Disease and Operative Indexes

• Physician Index • Master Patient Index

• Financial data

• Patient Registration

• Registries • Disease registries

• Cancer registries • Trauma registries

• Birth Defects Registries

• Diabetes registries • Implants registries

• Transplant registries

• Immunization registries

Slide 18 Secondary Health Data • Users

• External Users • Individuals and institutions

• State data banks

• Federal agencies

• Generally aggregate data and not patient identifiable data

• Internal Users • Individuals within the organization

• Medical staff

• Administrative staff

• Fiscal management

• Management

• Used to identify patterns and trends

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Health Information Guidelines HIM functions usually involve ensuring the quality, security, and availability of health information as it follows the patient through the health system. The HIM department also monitors the quality of patient information, ensuring that the information is maintained and protected in accordance with federal, state, and local regulations and the guidelines issued by various accrediting bodies.

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• Coding guidelines and Coding Clinics

• NCCI Edits- National Correct Coding Initiative (NCCI) edits for Medicare and Medicaid are not the same. If you’re following Medicare edits for Medicaid claims, you may have claims denying inappropriately.

• JCAHO Standards

• Data set data collection

• Departmental and Organizational Policies

• Medicare and Medicaid Conditions of Participation

• Best practice standards nationally and regionally

– Record Retention & Destruction

• Federal and state regulations

– HIPAA and Release of Information

– Fraud and Abuse

HIM Guidelines

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HIM Policies & Procedures This is not a complete or inclusive list

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• Abbreviations

• Access to Automated/Computerized Records

• Access to Records (Release of Information) by Resident and by Staff

• Admission/Discharge Register

• Admission Procedures

• Facility Procedures— Establishing/Closing the Record

• Preparing the Medical Record

• Preparing the Master Patient Index

• Readmission—Continued Use of Previous Record

• Readmission—New Record

• Amendment of Clinical Records

• Audit Schedule

• Audit and Monitoring System

• Chart Removal and Chart Locator Log

• Clinical Records, Definition of Records, and Record Service

• Audit/Monitoring Schedule

• Admission/Readmission Audit

• Concurrent Audit

• Discharge Audit

• Specialized Audits (examples)

• Certification, Medicare

• Chart Removal and Chart Locator Log

• Clinical Records, Definition of Records, and Record Service

HIM Policies & Procedures

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• Access to Records

• Automation of Records (See also Computerization)

• Availability

• Change in Ownership

• Coding from home

• Completion and Correction of Records

• Confidentiality

• Definition of the legal record

• Indexes

• Ownership of Records

• Permanent and Capable of Being Photocopied

• Retention

• Storage of Records

• Subpoena

• Unit Record

• Willful Falsification/Willful Omission

General HIM Policies & Procedures

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• Closing the Record

• Coding and Indexing, Disease Index

• Committee Minutes Guidelines

• Computerization and Security of Automated Data/Records

• Confidentiality (See Release of Information)

• Consulting Services for Clinical Records and Plan of Service

• Content, Record (the list provided is not all-inclusive and should be tailored to the facility/corporation)

• Advanced Directives

• Transfer Form/Discharge Plan of Care

• Discharge against Medical Advice

• Physician Consultant Reports

• Medicare Certification/Recertification

• Physician Orders/Telephone Orders

• Physician Services Guidelines and Progress Notes

• Physician History and Physical Exam

• Discharge Summary

• Interdisciplinary Progress Notes

HIM Policies & Procedures

This is not a complete list, there are many more policies and procedures needed for HIM functions and operations. P&Ps will vary by type of facility.

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Healthcare Standards Educating clinicians on documentation and content using standards, regulation and processes such as CDI and RCM.

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• Facility-specific standards: Standards might be found in facility policies and procedures and, when a facility has an organized medical staff, in the medical staff bylaws, rules, and regulations. Facility-specific guidelines govern the practice of physicians and others within a specific organization.

• Licensure requirements: Before they can provide services, most healthcare organizations must be licensed by government entities such as the state or county in which they are located and must maintain a license as long as care is provided.

• Certification standards: Government reimbursement program standards are applied to facilities that choose to participate in federal programs such as Medicare and Medicaid. These standards are titled Conditions of Participation or Conditions for Coverage. Facilities are said to be certified if the standards are met.

• Accreditation standards: Accreditation is the end result of an intensive external review process that indicates a facility has voluntarily met the standards of the independent accrediting organization. (Sayles, 2014)

Types of Standards

Slide 27 Example: JCAHO & CMS Documentation Standards

• Medical History & Physical Examination • Within 24 hours of admission

• Prior to surgery

• If using readmission MH&P, must be within 30 days of readmission, of the same condition, reviewed and updated by the attending physician

• Operative Report • As soon as possible post procedure but no later than 24 hours post

operatively

Slide 28 Example: JCAHO & CMS Documentation Standards

• Patient’s record must be completed within 30 days of discharge

• Discharge summary must be completed as soon as possible post discharge but no later than 30 days post discharge

• Deemed Status

• Health care organizations have "deemed status" and are not be subject to the Medicare survey and certification process because it has already been surveyed by the accrediting organization, such as JCAHO. Accreditation is voluntary and seeking deemed status through accreditation is an option, not a requirement (CMS, 2017)

Slide 29 Content and Documentation Supports Medical Necessity

• Medical necessity is defined as services or supplies required to diagnose or treat a medical condition to meet accepted standards of medical practice.

• Services covered may include: • Physicians’ services

• Outpatient care

• Home health care

• DME

• Ambulance

• Preventive services

Slide 30 Meaningful Use Meaningful Use is a Medicare and Medicaid program that awards incentives for using certified electronic health records (EHRs) to improve patient care. To achieve Meaningful Use and avoid penalties, providers must follow a set of criteria that serve as a roadmap for effectively using an EHR.

• Term used by federal government incentive program launched in 2011 to ensure implementation of EHR systems by eligible providers

• 2 Components to the MU program • Component 1 is managed by ONC and specifies the functionality an EHR must

have in order for meaningful users to earn the financial incentives

• Component 2 is specified by CMS (2014) to pay physicians over a 3 stage implementation • Stage 1 – 2011 working into 2012

• Stage 2 – 2014 extended to 2016

• Stage 3 – 2016but delayed until 2017

• Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) ended the Sustainable Growth Rate formula (source: https://qpp.cms.gov/)

Slide 31 Flow chart of meaningful use of improved healthcare delivery

Slide 32 National Patient Safety Goals

The National Patient Safety Goals (NPSGs) have become a critical method by which The Joint Commission promotes and enforces major changes in patient safety. The criteria used for determining the value of these goals, and required revisions to them, are based on the merit of their impact, cost, and effectiveness.

• NPSG require healthcare organizations to eliminate wrong-site, wrong-patient, and wrong-procedure surgery.

• Organizations must create and use preoperative verification process, such as checklist to confirm patient identity and appropriate documentation

• Data collected used to focus on accreditation survey on patient safety and high quality care

• Selecting specific patients to trace through the organization.

Slide 33 Clinical Documentation Improvement

• CDI is the process an organization uses to improve clinical specificity and documentation. • allow coders to assign more concise classification codes.

• CDI metrics are key indicators used to monitor the effectiveness of a CDI Program.

• Key indicator is a quantifiable measure used over time to determine whether some structure, process, or outcome in the provision of care to a patient support high quality performance measured against best practice criteria. • Widely used key indicate: Case Mix Index

Slide 34 Information Governance

• Information Governance focuses on principles and oversight to manage the information that is produced from the different systems within an organization

• Data Governance is enterprise authority that ensures control and accountability for enterprise data through the establishment of decision rights and data policies and standards that are implemented and monitored through a formal structure of assigned roles, responsibilities, and accountabilities.

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• Creates responsibility for data trough principles and practices to “ensure the knowledgeable and appropriate use of data derived from individuals’ personal heath information.” (Kanaan & Carr, 2009)

• Data stewardship is created to establish common and essential practices and principles for health data management.

Data Stewardship

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• National Committee on Vital and Health Statistics recommends creation of 4 categories of clearly defined principles for data stewardship

– Individual’s rights

– Data steward responsibilities

– Needed security safeguards and controls

– Accountability, enforcement and remedies for data stewardship

Data Stewardship

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Maintaining the MPI Probably the most important index used by the HIM department is the master patient index (MPI).

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“The MPI is the permanent record of every patient ever seen in the healthcare entity. The MPI functions as the primary guide to locating pertinent demographic data about the patient and his or her health record number. Without the information contained in the MPI, it would be almost impossible to locate a patient’s health record in most organizations that use a numeric filing system. The demographic information entered in the PMI supplies the patient identifying information for the health record and its supporting databases. Therefore the MPI is the initial point of documentation of the health record. An enterprise master patient index (EMPI) references all patients in two or more facilities (e.g. integrated healthcare delivery system or health information exchange [HIE]).” (Sayles, 2014)

Master Patient Index

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• Quality Issues in MPI Systems

• Duplicate, Overlay, and Overlap Medical Record Number Issues

• The management of a high-quality, error-free MPI requires constant maintenance that includes oversight, evaluation, and correction of errors. The responsibility for MPI maintenance should be centralized under the direction of a qualified professional. A comprehensive maintenance program should include:

– Ongoing process to identify and address existing errors

– Advanced person search capabilities for minimizing the creation of new errors

– Mechanism for efficiently detecting, reviewing, and resolving potential errors

– Ability to reliably link different medical record numbers and other identifiers for the same person to create an enterprise view of the person

– Consideration of the types of physical merges (files, film, and such) and the interfaces and correction routines to other electronic systems that are populated or updated by the EMPI

Maintenance of Master Patient Index

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• MPI maintenance policies and procedures also should be outlined:

– Whether to use the most recent information for each data element or criteria for determining which data elements will be stored as the patient’s information

– Identification of duplicate data elements (for example, prior names or aliases)

– Communication of merges to ancillary staff for source system revision

– Regular review of error reports and trending of duplicate percentages (AHIMA 2010b)

Maintenance of Master Patient Index

Slide 41 For more information

• Health Information Management Technology: An Applied Approach by N. Sayles

• Review Coding Guidelines and Coding Conventions

• HIPAA Standards

• CMS.gov

• JCAHO.org