HIM Assignment
© 2016
Chapter 3: Health Information Functions, Purpose, and Users
Health Information Management Technology: An Applied Approach
Introduction
• Who, what, when, why, and how of patient care
• Data
• Information
Primary Purposes of the Health Record
• Patient care
• Management of patient care
• Administrative processes
Secondary Purposes
• Education of healthcare professionals
• Legal, accreditation, and policy development
• Public health and research
Formats of the Health Record
• Paper health record
• Electronic health record
• Hybrid health record
Users of the Health Record
• Healthcare providers are primary users
o Uses
• Patient record
• Aggregated
• De-identification
Users of the Health Record
• Individual Users
o Patient care providers
o Patient care managers and support staff
o Coding and billing staff
o Patients
o Employers
o Lawyers
Users of the Health Record
• Individual users continued
o Law enforcement officials
o Healthcare researchers and clinical investigators
o Government policy makers
Users of the Health Record
• Institutional users
o Healthcare delivery organizations
o Third-party payers
o Medical review organizations
o Research organizations
o Educational organizations
Users of the Health Record
• Institutional users continued
o Accreditation organizations
o Government licensing agencies
o Policy-making bodies
HIM Functions
• Common HIM functions
o Record processing
o Monitoring of record completion
o Transcription
o Release of patient information
o Clinical coding, abstracting and clinical data analysis
HIM Functions
• Other functions
o Research and statistics
o Registries
o Birth and death certificates
HIM Functions
• Work with other departments
o Patient care
o Information governance
o Quality management
o Billing
o Patient registration
Master Patient Index
• Permanent record of all patients treated at facility
o Demographics
o Used in numeric filing system
o Enterprise master patient index
Master Patient Index – 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
• 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
Master Patient Index
• Quality issues in MPI systems
o Typographical errors
o Outdated demographic information
o Incorrect names
o Duplicate
o Overlay
o Overlap
Master Patient Index
• MPI quality control
o Algorithms
• Deterministic
• Probabilistic
• Rules-based
Identification Systems
• Health record number: a unique identifier
• Paper-based health record
o Serial numbering
o Unit numbering
o Serial-unit numbering
o Alphabetic
Identification Systems
• Electronic health records
o Unit health record
o Patient account number
HIM Functions in Paper-Based Environment
• Record storage and retrieval functions
o Alphabetic
o Numeric
• Straight numeric
• Terminal–digit
• Alphanumeric
o Centralized unit
HIM Functions in Paper-Based Environment
• Record storage and retrieval functions
o Filing cabinets
o Shelving units
• Open
• Compressible
HIM Functions in Paper-Based Environment
• Purging of health record depends on:
o Space
o Readmission rate
o Access to record
HIM Functions in Paper-Based Environment
• File folder
o Color coding
• Microfilm
o Roll
o Jacket
o microfiche
HIM Functions in Paper-Based Environment
• Off-site storage
o Facility or commercial company
o Protect records
• Privacy
• Physical
o Access
HIM Functions in Paper-Based Environment
• Image-based
o Scanned document
o Index
o Cannot search
HIM Functions in Paper-Based Environment
• Retrieval and tracking
o Outguide
o Loose material
o Requisition
o Chart tracking system
HIM Functions in Paper-Based Environment
• Record processing of paper-based records
o Organize
o Meet standards
o Record reconciliation
o Assembly
o Analysis
• Qualitative
• Quantitative
HIM Functions in Paper-Based Environment
• Completion
o Incomplete record
o Delinquent record
HIM Functions in Paper-Based Environment
• Corrections o Draw line o Write “error” o Sign, date and time correction
• Addendum o Date of addendum o Signed and timed
• Amendment o Dated, timed, and signed
HIM Functions in Paper-Based Environment
• Forms design
o Easy to use
o Include all necessary data
o Users involved in development
HIM Functions in Paper-Based Environment
• Form design principles
o Unique form identification
o Date created or revised
o Title
o Facility name and logo
o Patient identification information
o Signature line
HIM Functions in Paper-Based Environment
• Form design principles
o Content in order of data entry, if appropriate
o OCR and barcodes – upper corner
o 8.5 x 11
o Black ink on white paper
o Sufficient space to write
HIM Functions in Paper-Based Environment
• Clinical forms committee o Interdisciplinary
o Standards for forms
o Tracking system
o Testing and evaluation of forms
o Approve new and revised forms
o Storage, inventory and distribution
o Database
HIM Functions in Paper-Based Environment
• Quality control
o Standards
o Monitoring
• Misfiles
• Timeliness of storage and retrieval
o Record completion
HIM Functions in an Electronic Environment
• Electronic health record
• Reducing storage of paper records
• Audit trail
• Indexing
• Record completion
• Work queue
HIM Functions in an Electronic Environment
• Version control
• Free text
• Structured data
HIM Functions in an Electronic Environment
• Copy and paste o Inaccurate or outdated information o Redundant information o Inability to identify the author or intent of
documentation o Inability to identify when the documentation was first
created o Propagation of false information o Internally inconsistent progress notes o Unnecessarily lengthy progress notes
HIM Functions in an Electronic Environment
• Digital dictation
• Voice recognition
o Natural language processing
• Reconciliation
• “other” documentation
o E-mail, voice mail, EKG, and more
HIM Functions in an Electronic Environment
• Materials from other facilities
o Policies
o State laws
o Consult attorney
• Search, retrieve, and manipulate health data
o Data mining
HIM Functions in an Electronic Environment
• Amendments and corrections
o Lock documents when authenticated
o Control who can unlock
o Share change with other systems
HIM Functions in an Electronic Environment
• Quality control
o Control data entered in EHR
• Scanning
• Data entry
• Barcodes
• Transfer of data
HIM Functions in an Electronic Environment
• Quality control
o Data entry
• Input mask
• Drop down box
• Check box
• Radio buttons
HIM Functions in an Electronic Environment
• Screen design o Clear navigations buttons
o Labeling of buttons and fields
o Limit abbreviations
o Consistent location of navigation buttons
o Alerts
o References
o Check
HIM Functions in an Electronic Environment
• Screen design
o Logical organization
o Neutral colors
o Undo buttons
o Confirmation buttons
o Require fields
o Title for screen
HIM Functions in an Electronic Environment
• Screen design
o Minimize keystrokes
o Appropriate field type
o Select from predefined lists when possible
o Data validation checks
Hybrid Record
• Part paper and part electronic
• Processes for both used
• Document management system
o Workflow
• Difficult to identify legal health record
Medical Transcription
• HIM or centralized department
• Outsourcing o Liaison
• Commonly transcribed documents o History and physical
o Discharge summary
o Pathology report
o Radiology report
Medical Transcription
• Monitor document for quality and timeliness
• Speech recognition
o Front-end
o Back-end
Release of Information
• Receive request for patient information
• Ensures request is appropriate
• Provides patient information
• Monitor quality of release and timeliness
• Record what is released
Clinical Coding
• Assign codes to diagnoses and procedures
• Abstracting
o Date of surgery
o Surgeon
o Disposition
HIM Interdepartmental Relationships
• Patient registration
• Billing department
• Patient care departments
• Information systems
• Quality management
• Virtual HIM
HIM Software
• Release of information
• Chart tracking
• Coding
• Registries
• Billing
• Quality improvement
HIM Software
• Electronic health record
o Meaningful use
• Certified electronic health record
• Personal health records