Project Presentation
Gwadys
AB103118_Ch03_PPT11.pptxHealth Information Management Technology: An Applied Approach, Sixth Edition
Chapter 3: Health Information Functions, Purpose, and Users
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1
Introduction
Who, what, when, why, and how of patient care
Data
Information
Knowledge
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Primary Purposes of the Health Record
Patient care
Management of patient care
Administrative processes
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Secondary Purposes
Education of healthcare professionals
Legal, accreditation, and policy development
Public health and research
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Formats of the Health Record
Paper health record
Electronic health record
Hybrid health record
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Primary Users – Healthcare Providers
Patient record
Aggregated
Deidentification
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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
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Institutional users
Healthcare delivery organizations
Third-party payers
Medical review organizations
Research organizations
Educational organizations
Accreditation organizations
Government licensing agencies
Policy-making bodies
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Medical Transcription and Voice Recognition
Transcription
In-house or outsourced
Documents transcribed
Transcription supervisor
Quality of reports
Timeliness of transcription
Speech recognition
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Release of Information
Disclosing patient-identifiable information
In-house or outsourced
ROI supervisor
Monitor quality
Turnaround time
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Clinical Coding and Reimbursement
Coding
Abstracting
Bill
Coding supervisor
Quality of codes
Timeliness
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Record Storage and Retrieval
Transitioning from paper to electronic
Document management system
Hybrid health record
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Master Patient Index
Permanent record of all patients treated at healthcare organization
Demographics
Used in numeric filing system
Enterprise master patient index
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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
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
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Quality Issues in MPI Systems
Typographical errors
Outdated demographic information
Incorrect names
Duplicate
Overlay
Overlap
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Algorithms
Deterministic
Probabilistic
Rules-based
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Paper-based Filing Systems
Alphabetic
Numeric
Straight numeric
Terminal-digit
Alphanumeric
Centralized unit
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Paper-based Storage
Filing cabinets
Shelving units
Open
Compressible
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Purging
Space
Readmission rate
Access to health record
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Paper-Based Storage
Image-based
Scanned document
Index
Cannot search document
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Paper-based Storage
File folder
Color coding
Microfilm
Roll
Jacket
Microfiche
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Off-site Storage
Healthcare organization or commercial company
Protect records
Privacy
Physical
Access
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Paper-Based Retrieval and Tracking
Outguide
Loose material
Requisition
Chart tracking system
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Paper-based Record Processing
Organize
Meet standards
Record reconciliation
Assembly
Analysis
Qualitative
Quantitative—concurrent or retrospective
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Monitoring Completion
Deficiency slip
Incomplete health records
Delinquent record
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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
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Form Design
Identify purpose of form
Include all necessary data
Users involved in development
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Form Design Principles
Unique form identification
Date created or revised
Title
Facility name and logo
Patient identification information
Signature line
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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
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Clinical Forms Committee
Interdisciplinary
Standards for forms
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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
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Quality Control
Standards
Monitoring
Misfiles
Timeliness of storage and retrieval
Record completion
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Electronic Environment
Reducing storage of paper records
Audit trail
Indexing
Health record completion
Work queue
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Electronic Environment
Version control
Free text
Structured data
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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
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Electronic Environment
Digital dictation
Speech recognition
Natural language processing
Reconciliation
E-mail, voice mail, EKG, and more
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Electronic Environment
Materials from other healthcare organizations
Search, retrieve, and manipulate health data
Data mining
Amendments and corrections
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Quality Control—Data Entry
Scanning
Data entry
Barcodes
Transfer of data
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Quality Control—Data Entry
Input mask
Drop down box
Check box
Radio buttons
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Screen Design
Clear navigations buttons
Labeling of buttons and fields
Limit abbreviations
Consistent location of navigation buttons
Alerts
References
Check
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Screen Design
Logical organization
Neutral colors
Undo buttons
Confirmation buttons
Require fields
Title for screen
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Screen Design
Minimize keystrokes
Appropriate field type
Select from predefined lists when possible
Data validation checks
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Identification Systems
Health record number: a unique identifier
Paper-based health record
Serial numbering
Unit numbering
Serial-unit numbering
Alphabetic
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EHR—Unit Numbering
Patient account
Health record number
Other identifiers
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Other HIM Functions
Statistics
Research
Registries
Birth and death certificates
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HIM Functions
Work with other departments
Patient care
Information governance
Quality management
Billing
Patient registration
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HIM Interdepartmental Relationships
Patient registration
Billing department
Patient care departments
Information systems
Quality management
Virtual HIM
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HIM Information Systems
Release of information
Chart tracking
Coding
Registries
Billing
Quality improvement
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HIM Information System
Electronic health record
Personal health records
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